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ANSWERS 


TO 


QUESTIONS   PRESCRIBED 


BY 


MEDICAL  STATE  BOARDS 


BY 

ROBERT  B.  LUDY,  M.  D., 

LATE    ACTING-ASSISTANT   SURGEON,    U.   S.    A.:     LECTURER  ON    PRACTICE    OF   MEDICINE    IN   TEMfLE 

COLLEGE   OF   PHILADELPHIA;    AUTHOR   OF   ANSWERS   TO   "QUESTIONS    PRESCRIBED 

BY    DENTAL   STATE   BOARDS;"    "ANSWERS  TO   QUESTIONS    PRESCRIBED 

BT   PHARMACEUTICAL   STATE   BOARDS,"    ETC. 


FOURTH   EDITION 

REWRITTEN  AND  ENLARGED 


I'JIILADKM'IIIA 

JOHN  JOS..  McVEY 
1910 


Hcif 


Entered  according  to  the  Act  of  Congress,  in  the  year  1910, 

By  JOHN  JOS.  McVEY 

In  the  Office  of  the  Librarian  at  Washington,  D.  C. 


/Tc/i'Jd^ 


PREFACE  TO  FOURTH  EDITION. 


The  large  sale  of  this  work  ha,s  permitted  the  early  prep- 
aration of  a  fourth  revision.  The  entire  text  has  been  care- 
fully scrutinized,  corrected  where  necessary,  revised  and 
abbreviated  where  improvement  could  be  made,  and  added 
to  by  the  incorporation  of  recent  examination  questions  and 
answers.  This  fourth  edition  has  been  edited  throughout  by 
Charles  Piatt,  M.  D.,  Ph.  D.  Robert  B.  Ludy. 


PREFACE  TO  SECOND  EDITION. 


The  indorsement  of  the  first  edition  of  this  book  by  teach- 
ers and  students  as  shown  by  numoi-ous  expressions  of  ap- 
proval, as  well  as  by  its  rapid  sale,  is  extremely  gratifying  to 
the  author  and  seems  to  warrant  its  continuance. 

All  new  State  Board  questions  which  have  appeared  since 
the  publication  of  the  first  edition  have  been  added.  It  is 
hoped  that  the  careful  revision  to  which  the  work  has  been 
subjected  has  eliminated  the  errors  which  appeared  in  the 
first  edition. 

Everything  has  been  sacrificed  to  brevity  and  accuracy,  so 
that  students  will  find  the  book  indispensable  in  preparing 
for  college,  hospital,  army  and  navy  examinations  in  the 
shortest  possible  time. 

Many  persons  having  an  ade(|uate  knowledge  of  the  sub- 

(iii) 


iv  PREFACE  TO  SECOND  EDITION.  ' 

ject  in  which  they  are  tested,  fail  because  of  their  inability  to 
interpret  properly  the  intents  and  purposes  of  the  questions 
to  be  answered  by  them.  To  aid  in  this,  as  well  as  to  afford 
a  convenient  manual  for  the  general  preparation  of  medical 
students  in  their  work,  is  the  sole  object  of  this  book, 

HavitLg  collected  a  large  number  of  questions  from  differ- 
ent States,  it  was  found  that  duplications  occurred  ranging 
from  30%  to  80%,  varying  according  to  the  several  subjects. 
Thus  a  comprehensive  knowledge  of  these  questions  and  an- 
swers will  serve  excellently  in  the  preparation  of  future  ex- 
aminations before  such  Boards. 

In  order  to  secure  a  critical  interpretation  of  the  questions, 
and  concise,  yet  complete,  answers  to  the  same,  the  author  has 
been  favored  by  the  assistance  of  well-known  specialists  in 
their  several  lines,  whose  competence  and  experience  give  to 
the  work  a  range  and  value  impossible  of  attainment  in  the 
product  of  a  single  author. 

To  them  the  author  makes  grateful  acknowledgment.  The 
high  value  of  their  carefully  prepared  answers  is  fully  appre- 
ciated by  him,  and  will  be  by  those  into  whose  hands  the  work 
is  committed.  Robert  B.  Ludy. 


SPECIAL  AUTfiOKS. 


Charles  Piatt,  A,  C,  M.  D.  Ph.  D.,  JF.  C.  8.  London. 

Author  of  Piatt's  Medical  Chemistry. 

Herbert  L.  North,  31.  D. 

Dean  and  Professor  of  Anatomy,  and  Associate  Professor  of 
Surgery  in  the  Hahnemann  Medical  College  and  Hospital  of 
Philadelphia. 

John  C.  Scott,  P.  D.,  M.  D. 

Demonstrator  of  Physiology  at  the  Medico-Chirurgical  College 
of  Philadelphia. 

W.    Wayne  Bahcock,  M.  1). 

Professor  of  Surgery  and  Clinical  Surgery  in  Temple  College 
of  Philadelphia;  Assistant  Pathologist  to  the  Philadelphia  Hos- 
pital, and  .Joint  Author  of  Vol.  V.,  Cohen 's  System  of  Physiologic 
Therapeutics. 

Arthur  C.  Morgan,  31.  D. 

Visiting  Physician  to  the  Tuberculosis  Department  of  the 
Philadelphia  General  Hospital. 

W.  Hersey  Thomas,  31.  J). 

Assistant  Professor  of  Surgery  in  the  Medico-Chirurgical  Col- 
lege of  Philadelphia;  Assistant  Surgeon  to  the  Medico-Chirur- 
gical and  Philadelphia  Hospitals. 

W.  A.  Newman  JDorland,  31.  D. 

Assistant  Obstetrician,  Hospital  of  the  University  of  Pennsyl- 
vania;   Author   of  "  Modern   Obstetrics,"   System    of   American 
Medical  Dictionaries,  "  The  Age  of  Mental  Virility,"  etc. 
(V) 


CONTENTS. 

PACSB 

I.  Chemistry   1 

By  Charles  Piatt,  M.  D.,  Ph.  D. 

II.  Anatomy 147 

By  Herbert  L.  Northrop,  M.  D. 

III.  Physiology 213 

By  John  C.  Scott,  P.  D.,  M.  D. 

IV.  Pathology  and  Bacteriology   281 

By  W.  Wayne  Babeock,  M.  D. 

V.  Therapeutics  and  Materia  Medic  a  313 

By  Arthur  C.  Morgan,  M.  D. 

VI.  Diagnosis  and  Practice 407 

By  Arthur  C.  Morgan,  M.  D. 

VII.  Hygiene   513 

By  Arthur  C.  Morgan,  M.  D. 

VIII.  Surgery 553 

By  W.  Hersey  Thomas,  M.  D. 

IX.  Obstetrics  and  Gynecoix)gy  653 

By  W.  A.  Newman  Borland,  M.  D. 
(vii) 


CHEMISTRY. 


Define  (a)  chemistry,  (b)  atom,  (c)  compound,  (d)  mix- 
ture, (e)  ion. 

Chemistry  is  that  science  which  treats  of  the  composition 
of  matter  and  of  the  changes  which  this  composition  may 
undergo. 

An  atom  is  the  smallest  particle  into  which  matter  can  be 
divided — the  smallest  particle  of  matter  capable  of  entering 
into  a  chemical  combination. 

A  compound  is  a  substance  composed  of  at  least  two  differ- 
ent elements  chemically  combined.  The  properties  of  a  com- 
pound are  generally  different  from  those  of  its  constituents. 

In  a  mixture  the  ingredients  may  be  present  in  any  pro- 
IK)rtion.  The  properties  of  a  mixture  are,  in  general,  the 
sum  of  the  properties  of  its  ingredients. 

An  ion  is  one  of  the  parts  into  which,  by  electrolytic  disso- 
ciation, a  molecule  divides  on  entering  into  solution. 

Define  and  illustrate  (a)  tetrads,  (b)  pentads. 

A  tetrad  is  an  element  with  a  valence  of  four,  i.  e.,  equal  to 
that  of  four  atoms  of  hydrogen.    Example — carbon,  CH4. 

A  pentad  is  an  element  with  a  valence  of  five,  i.  e.,  equal  to 
that  of  five  atoms  of  hydrogen.    Example — phosphorus,  PCI5. 

Give  the  occurrence  in  nature,  the  preparation  and  the 
properties  of  oxygen. 

Oxygen  occurs  in  nature,  in  the  free  state,  forming  about 
one-fifth  of  the  atmosphere.  In  combination  in  nature  it 
forms  eight-ninths  of  water — ^and  is  found  in  nearly  all  ani- 
mal, vegetable,  and  mineral  compounds. 

It  is  prepared  by  heating  mercuric  oxide,  or  by  heating 

(1) 


2  CHEMISTRY. 

potassium  chlorate,  best  after  addition  of  a  little  manganese 
dioxide. 

It  is  a  colorless,  odorless,  tasteless  gas,  a  little  heavier  than 
air,  only  slightly  soluble  in  water.  It  supports  combustion 
and  unites  with  most  other  elements  to  form  oxides. 

What  is  chemical  affinity? 

Chemical  affinity,  or  chemism,  is  that  force  which  combines 
atoms  to  form  molecules. 

Mention  three  fixed  monads,  two  fixed  dyads,  one  fixed 
triad  and  three  elements  that  vary  in  valency.     Illustrate. 

Monads ;  hydrogen,  chlorine,  and  bromine.  Hydrogen  is 
the  standard  of  comparison,  chlorine  and  bromine  are  shown 
to  be  monads  in  their  compounds,  hydrochloric  acid,  HCl, 
hydrobromic  acid,  HBr,  etc.  In  no  known  compounds  will 
these  elements  combine  with  more  than  one  hydrogen  atom. 

Dyads;  oxygen  and  calcium,  as  shown  in  the  compounds, 
water,  HgO,  calcium  chloride,  CaClj. 

Triad;  boron,  as  shown  in  the  oxide,  B2O3,  two  atoms  of 
boron  combining  with  the  three  bivalent  oxygen  atoms. 

Three  elements  varying  in  valency  are :  Carbon,  dyad  in 
CO,  tetrad  in  CO2;  sulphur,  tetrad  in  SOj,  hexad  in  SOg; 
gold,  monad  in  AuCl,  triad  in  AuClj. 

Differentiate  mechanical  divisibility  and  chemical  di= 
visibility. 

Mechanical  divisibility,   that  obtainable  by  mechanical  or- 
physical  means,  permits,  theoretically,  the  division  of  matter 
into  its  molecules. 

Chemical  divisibility,  that  obtainable  by  chemical  means, 
permits  of  the  division  of  matter  into  its  atoms. 

What  are  salts  and  how  are  they  formed?  Define 
neutral  salt,  acid  salt,  double  salt. 

Salts  are  compounds  formed  from  acids  by  substituting 
metals  or  basic  radicals  for  part  or  all  of  the  replacealble 
hydrogen  of  the  acid. 

Neutral  salts  are  those  foi-med  from  acids  by  substituting 


CHEMISTBY.  3 

metals  or  basic  radicals  for  all  of  the  replaceable  hydrogen  of 
the  acid. 

Acid  salts  are  those  formed  from  acids  by  substituting 
metals  or  basic  radicals  for  part  of  the  replaceable  hydrogen 
of  the  acid. 

Double  salts  are  those  containing  two  different  metals  or 
basic  radicals  in  their  molecule. 

Mention  five  elements  found  in  nature  only  in  combin= 
ation.    Into  what  groups  are  elements  divided? 

Aluminum,  potassium,  sodium,  chlorine  and  bromine. 

Elements  may  be  classified  according  to  their  electro-chem- 
ical properties,  e.  g.,  the  electro-negative  non-metals,  the 
electro-positive  metals;  they  may  be  classified  according  to 
their  analytical  properties,  e.  g.,  those  precipitated  by  hydro- 
chloric acid,  those  precipitated  by  hydrosulphuric  acid,  etc.; 
they  may  be  classified  according  to  their  atomic  weights  (the 
periodic  law),  thus  bringing  together  in  groups  elements 
similar  in  properties. 

Mention  five  elementary  substances  commonly  used  in 
medicine  in  a  pure  or  uncombined  state. ^ 

Oxygen,  iodine,  sulphur,  phosphorus,  carbon. 

Define  reaction,  water  of  crystallization,  atomic  weight, 
specific  gravity,  reagent. 

Reaction — the  rearrangement  of  atoms  with  formation  of 
■  new  compounds  effected  in  a  chemical  change.  Water  of 
crystallization — water  necessai-y  to  the  crystal  form.  Atomic 
weight — the  relative  weight  of  an  atom  as  compared  with 
the  weight  of  another  atom  taken  as  a  standard.  Specific 
gravity — the  relative  weight  of  a  substance  as  comj)ared  with 
the  weight  of  an  equal  volume  of  another  substance  taken  as 
a  standard.  Reagent — a  substance  used  to  produce  a  chemical 
reaction. 

Define  isomorphous,  amorphous,  crystalline,  galvanic, 
polarization. 

Isomorphous — of  the  same  form,  relating  in  chemistry  gen- 


4  CHEMISTRY. 

erally  to  substances  which  crystallize  in  the  same  form. 
Amorphous — without  form,  substances  having  no  regularity 
of  internal  structure,  not  crystalline.  Crystalline — substances 
having  a  regularity  of  internal  molecular  structure  produc- 
ing under  proper  conditions  definite  geometrical  forms.  Gal- 
vanic— that  pertaining  to  electricity  of  chemical  origin  to 
current  electricity.  Polarization- — in  reference  to  light,  means 
the  breaking  up  of  the  light  ray  into  two  parts  whose  planes 
of  vibration  are  at  right  angles  to  each  other.  Polarization 
in  electrical  batteries  refers  to  the  accumulation  of  gas  on  the 
plates,  thereby  interfering  with  the  further  production  of 
the  electric  current. 

Describe  a  method  of  producing  an  electric  current  by 
chemical  action. 

In  a  jar  eontaining  water  rendered  slightly  acid  with  sul- 
phuric acid,  place  a  plate  of  copper  and  one  of  zinc;  connect 
the  two  plates  outside  of  the  liquid  by  means  of  a  wire  and  a 
current  of  electricity  will  be  developed,  "  flowing  "  from  the 
zinc  to  the  copper  through  the  liquid,  and  from  the  copper  to 
the  zinc  through  the  wire. 

Explain  the  uses  of  the  spectroscope  in  chemical  analysis, 

A  solid  body  at  a  white  heat  produces  a  "  continuous  spec- 
trum." Elementary  substances  in  the  state  of  gas  or  vapor 
when  highly  heated  yield  characteristic  spectra  consisting  of 
but  one  or  more  bright  lines,  the  position  of  which  is  positively 
fixed  for  each  element.  If  a  strong  white  light  be  passed 
through  certain  solutions  we  obtain  a  continuous  spectrum 
crossed  by  dark  lines — "  an  absorption  spectrum."  These 
facts  are  made  use  of  in  the  examination  of  heated  vapors 
and  of  certain  solutions.  In  medicine  the  spectroscope  is 
especially  useful  in  the  identification  of  blood  by  its  absorp- 
tion spectrum. 

Give  the  preparation  and  properties  of  iodine.  How  is 
potassium  iodide  prepared? 

Iodine  is  prepared  by  heating  a  mixture  of  sodium  iodide, 
sulphuric  acid  and  manganese  dioxide. 


CHEMISTRY.  5 

It  is  a  bluish-black  crystalline  solid,  occurring  in  lustrous 
scales  which  emit  a  pungent  characteristic  vapor.  It  is  but 
slightly  soluble  in  water,  but  is  soluble  in  water  containing 
potassium  iodide,  and  in  alcohol.  The  crystals  of  iodine  when 
heated  sublime  in  the  form  of  a  violet-colored  vapor. 

Potassium  iodide  may  be  made  by  acting  upon  ferrous 
iodide  with  potassium  carbonate. 

Fel2+K2C03=FeC03+2KI. 

Define  (a)  Distillation  (b)  Galvanic  cell. 

(a)  The  vaporization  of  a  liquid  with  the  subsequent  con- 
densation of  the  vapor. 

(b)  An  arrangement  of  two  dissimilar  elements  immersed 
separately  in  a  liquid,  which  acts  upon  one  of  them  more  than 
upon  the  other,  joined  outside  of  the  liquid  by  means  of  a 
wire. 

Or,  simply,  an  arrangement  by  which  a  flow  of  electricity 
is  generated  by  chemical  action. 

Define  and  illustrate  (a)  monad,  (b)  diad,  (c)  triad. 

A  monad  is  a  substance  with  a  combining  power  equal  to 
that  of  one  atom  of  hydrogen.  Example,  CI,  combining  with 
hydrogen  to  form  HCl. 

A  diad  (dyad)  is  a  substance  with  a  combining  power  equal 
to  that  of  two  atoms  of  hydrogen.  Example,  0,  combining 
with  hydrogen  to  form  IToO. 

A  triad  is  a  substance  with  a  combining  power  equal  to  that 
of  three  atoms  of  hydrogen.  Example,  N,  combining  with 
hydrogen  to  form  NH3. 

Define  (a)  latent  heat,  (b)  specific  heat. 

Latent  heat  is  the  heat  energy  used  to  overcome  molecular 
cohesion.  It  is  the  heat  apparently  lost  or  absorbed  when  a 
wlid  changes  to  a  liquid,  or  a  liquid  to  a  gas. 

Specific  heat  is  the  relative  amount  of  heat  required  to  raise 
equal  weights  of  substances  through  equal  degrees  of  tem- 
perature. 


6  CHEMISTRY. 

Give  the  preparation,  properties,  and  important  com  = 
pounds  of  chlorin. 

Chlorine  may  be  made  by  heating  a  mixture  of  sodium 
chloride,  sulphuric  acid  and  manganese  dioxide.  It  is  a 
yello^vish-green  pungent  gas,  very  irritating  to  the  air-pas- 
sages. It  is  two  and  one-half  times  heavier  than  air  and  is 
soluble  in  water,  forming  "  chlorine  water  ".  Important 
compounds  are  hydrochloric  acid,  nitro-hydrochloric  acid, 
sodium  chloride,  potassium  chloride  and  various  other  metallic 
chlorides,  sodium  and  calcium  hypochlorites. 

Describe  a  method  for  detecting  the  presence  of  lead 
salts  in  water. 

Evaporate  the  water  in  a  clean  dish  to  a  small  bulk  and  add 
a  few  drops  of  ammonium  sulphide — ^the  lead  will  be  precipi- 
tated as  the  brownish-black  sulphide,  insoluble  in  dilute 
hydrochloric  acid  (distinction  from  iron). 

Give  the  formula  and  properties  of  hydrocyanic  acid. 

Hydrocyanic  acid,  HON  or  HCy,  is  a  colorless  liquid,  vola- 
tile, of  characteristic  odor  and  taste  resembling  that  of  bitter 
almonds.  It  is  soluble  in  water  and  is  used  medicinally  in  a 
2  per  cent,  solution — acidum  hydrocyanicum  dilutum. 

Complete  the  following  equations. 
CuS0,+H2S= 

2NaN03+H2S0,= 

CuSO^+H^S^CuS+H^SO^. 
2NiaN03-fH2S04=Na2S04+2HN03. 

What  is  the  chemical  antidote  for  (a)  iodin,  (b) 
strychnine? 

The  chemical  antidote  for  iodine  is  starch.  There  is  no 
satisfactory  chemical  antidote  for  strychnine,  though  strong 
decoction  of  tannin  may  so  act.  The  treatment  is  rather  by 
^^se  of  physiological  antidotes  such  as  potassium  bromide  and 
other  sedatives. 


CHEMISTRY.  7 

Give  the  characteristic  properties  of  matter  in  (a)  the 
solid  state,  (b)  the  liquid  state,  (c)  the  gaseous  state. 

(a)  In  the  solid  state  the  cohesive  force  between  molecules 
is  greater  than  the  repelling  force.  The  body  has  definite 
form  independent  of  any  containing  vessel.  The  molecules 
have  limited  motion. 

(b)  In  a  liquid  the  cohesive  and  repelling  forces  are  nearly 
equal. 

(c)  In  a  gas  the  cohesive  force  is  less  .than  the  repelling 
force.  The  molecules  tend  to  separate  indefinitely  unless  con- 
fined. 

State  in  units  of  another  system  the  equivalent  of  (a) 
one  meter,  (b)  one  liter,  (c)  one  gram. 

(a)  One  meter=3.28  feet  or  39.37  inches. 

(b)  One  ^^-=33.8  U.  S.  fluid  ounces. 

(c)  One  gram=15.43  grains. 

Give  the  preparation  and  properties  of  SOg. 

Sulphur  dioxide,  SO2,  may  be  prepared  by  burning  sulphur 
in  the  air.  It  is  a  colorless  gas  with  pungent,  suffocating 
odor,  very  soluble  in  water,  forming  sulphurous  acid,  H2SO3. 

What  are  the  properties  and  uses  of  HF? 

Hydrofluoric  acid,  HF,  is  a  colorless  fuming  liquid  boiling 
at  19°  C.  It  is  soluble  in  water,  forming  a  colorless  corrosive 
liquid,  highly  injurious  to  the  skin.  The  acid  is  used  chiefly 
for  etching  upon  glass. 

Give  the  occurrence  in  nature,  the  preparation  and  the 
properties  of  nitrogen. 

Nitrogen  occni-s  in  the  free  state  in  the  atmosphere,  and  in 
combination  it  is  found  in  some  mineral  compounds  and  in 
many  animal  and  vegetable  compounds. 

It  is  prepared  by  passing  air  over  ineandescent  copper — 
or  by  heating  ammonium  nitrite. 

It  is  a  colorless,  odorless,  tasteless  gas.  a  little  lighter  than 
air,  incombustible,  a  non-supporter  of  combustion,  does  not 
support  life,  is  not  poisonous. 


8  CHEMISTRY. 

How  is  boric  acid  prepared  from  borax?  State  the 
properties  of  boric  acid. 

By  treating  the  borax  in  solution  with  hydrochloric  acid. 

Boric  acid  separates  in  white,  shining  scales  soluble  in  25 
parts  of  water  at  14°  C.  and  in  3  parts  of  boiling  water.  The 
solution  has  a  faint  acid  reaction.  Its  chief  use  in  medicine  is 
as  a  mild,  r on-irritating  antiseptic. 

State  the  uses  of  phosphorus.  Give  the  treatment  of 
phosphorus  poisoning. 

Phosphorus  is  used  in  medicine — and  is  used  in  making 
matches.  The  treatment  for  phosphorus  poisoning  includes 
the  use  of  copper  sulphate  as  antidote  and  emetic,  magnesia 
in  mucilaginous  drinks,  magnesium  sulphate,  hydrogen  per- 
oxide, inhalation  of  oxygen  or  of  ozone.  The  old  antidote  was 
old  oil  of  turpentine.    No  other  oils  should  be  given. 

What  is  the  principal  source  of  iodine? 

The  ashes  of  certain  sea  weeds — also  from  the  mother-liquor 
obtained  in  the  purification  of  Chili  saltpetre. 

Give  a  chemical  equation  showing  the  preparation  of 
ferrous  chloride. 

Fe+2HCl=FeCl2H-H2. 

Define  (a)  gravitation,  (b)  porosity,  (c)  osmosis,  (d) 
cohesion,  (e)  diffusion. 

Gravitation,  the  attraction  exerted  by  the  mass  of  the  earth. 

Porosity,  the  condition  of  being  porous — having  small  open- 
ings, or  pores. 

Osmosis,  that  property  by  which  liquids  and  crystallized 
substances  in  solution  pass  through  porous  septa. 

Cohesion,  the  mutual  attractive  force  between  molecules. 

Diffusion,  a  spreading  or  dissemination. 

Describe  the  preparation  of  CaCa  on  an  extensive  scale. 

Calcium  carbide  is  made  by  fusing  in  an  electric  furnace  a 
mixture  of  coal-tar  and  lime. 


CHEMISTRY.  9 

State  the  sources  and  the  properties  of  sulphur.  How 
are  flowers  of  sulphur  obtained? 

Sulphur  is  found  in  the  free  state  in  volcanic  regions,  also, 
combined  with  metals  in  the  form  of  sulphides,  and  sulphate. 
That  used  in  commerce  is  generally  obtained  by  purifying 
brimstone,  the  crude  sulphur  of  nature. 

Ordinary  sulphur  is  a  yellow,  brittle  solid,  or  a  fine  yellow 
powder.  It  melts  when  heated,  and,  in  the  air,  bums  to 
sulphur  dioxide.  Flowers  of  sulphur  are  obtained  by  sub- 
liming ordinary  sulphur. 

Describe  chlorin  as  to  (a)  atomic  weight,  (b)  valence, 
(c)  physical  properties,  (d)  solubility  in  water,  (e)  chem= 
ical  action. 

Chlorine,  at.  wt.  35.18,  valence  I,  is  a  yellowish-green  gas 
with  suffocating  odor,  soluble  in  water  ("  chlorine  water  "). 
Chemically  it  has  a  strong  affinity  for  hydrogen,  uniting  with 
it  to  form  hydrochloric  acid.  Indirectly  it  acts  as  an  oxidizing 
agent,  and  is  a  powerful  bleach. 

Give  the  name  and  formula  of  a  compound  of  sodium 
utilizable  (a)  as  a  preservative,  (b)  as  a  caustic,  (c)  as  a 
purgative. 

(a)  Borax,  sodium  tetraborate,  NaoB^OT-  (b)  Sodium  hy- 
droxide, NaOH.     (c)  Sodium  sulphate,  NazSO^. 

Give  two  tests  for  ferrous  salts. 

Potassium  ferrocyanide,  K^Fe(CN)6,  gives  a  bluish- white 
7>recipitate. 

Potassium  ferricyanide,  K.,Fe(CN)g,  gives  a  dark-blue  pre- 
cipitate. 

What  is  the  chemical  antidote  in  a  case  of  poisoning 
from  (a)  zinc  salts,  (b)  lead? 

The  chemical  antidote  for  zinc  salts  is  an  alkaline  carbon- 
ate: for  lead,  sodium  or  magnesium  sulphate. 


10  CHEMISTRY. 

Describe  a  chemical  method  of  determining  the  presence 
of  hydrargyrum  in  a  solution. 

Pass  HoS  gas  through  the  solution.  A  black  precipitate, 
insoluble  in  nitric  acid,  is/due  to  mercury. 

State  the  composition  and  the  properties  of  (a)  potas= 
sium  permanganate,  (b)  chromic  acid. 

Potassium  permanganate,  K2Mn208,  occurs  in  dark  reddish- 
pui'ple  crystals,  soluble  in  water.  Its  solutions  have  oxidizing 
and  disinfecting  properties,  especially  when  acidulated  with 
sulphuric  acid. 

Chromic  acid,  HaOrO^,  is  known  only  through  its  salts. 
The  question  probalbly  refers  to  chromic  anhydride  or 
chromium  trioxide,  CrOg,  which  is  sometimes  improperly 
called  chromic  acid.  This  occurs  in  reddish  crystals,  soluble 
in  water,  and  is  a  very  powerful  oxidizing  agent.  Used  in 
medicine  as  a  caustic. 

Define  sublimation,  distillation,  static  electricity,  gal  = 
vanic  cell,  organic  compound. 

Sublimation — the  vaporization  and  condensation  of  a  vola- 
tile solid.  Distillation — the  vaporization  and  condensation 
of  a  liquid.  Static  electricity — that  generated  by  friction. 
A  galvanic  cell  is  an  arrangement  of  elements  and  fluid  for 
the  production  of  electricity  by  chemical  action.  An  organic 
compound  is  a  hydrocarbon  or  a  substance  which  may  be  re- 
garded as  derived  from  a  hydrocarbon. 

Give  the  chemical  name  of  each   of  the  following:   (a) 
common  salt,  (b)  calomel,  (c)  sal=ammoniac,  (d)  plaster  of 
^  Paris,  (e)  a  principal  ingredient  of  baking  powder. 

(a)  Sodium  chloride,  (b)  mercurous  ehloride,  (e)  ammo- 
nium chloride,  (d)  calcium  sulphate,  (e)  sodium  bicarbonate. 

,       What  is  lunar  caustic?     State  how  lunar  caustic  is  pre- 
pared. 

Q  Lunar  caustic  is  moulded  silver  nitrate.     To  100  G^m.  of 

silver  nitrate  in  a  porcelain  dish  add  4  Gm.  of  hydrochloric 


CHEMISTRY.  11 

acid,  and  melt  the  mixture  at  as  low  a  temperature  as  pos- 
sible. Stir  well  and  pour  the  melted  mass  into  suitable 
moulds. 

Write  the  formulas  and  the  names  of  five  acids,  giving 
the  graphic  formula  of  one  of  them. 

Hydrochloric   acid,   HCl;   hydrobromic   acid,    HBr;    nitric 
acid,  HNO3;  sulphuric  acid,  H2SO4;  sulphurous  acid,  HjSOj. 
The  graphic  formula  for  nitric  acid  is 

O 

H-0— N 

W 
o 

How  may  ferric  hydrate  be  hurriedly  prepared?  When 
and  how  should  ferric  hydrate  be  used  as  an  antidote? 

Ferric  hydrate  may  be  prepared  by  adding  ammonia  water 
to  a  solution  of  ferric  sulphate.  "Wash  the  precipitate  by 
decantation  and  filter  through  unbleached  muslin. 

Ferric  hydrate  is  used  as  an  antidote  for  arsenic.  Give 
freely  mixed  with  waterjor  with  milk. 

Give  the  details  of  a  test  for  arsenic. 

The  Reinsch  test :  Acidify  \vith  hydrochloric  aeid,  introduce 
a  strip  of  pure,  clean  copper  foil  and  boil.  If  a  gray  coating 
form  on  the  copper,  remove  from  the  liquid,  dry  carefully 
by  pressing  between  folds  of  filter  paper,  place  the  copper  at 
the  bottom  of  an  ignition  tube,  and  lieat.  If  the  deposit  upon 
the  copper  be  arsenic  it  will  volatilize  and  will  deposit  on  tbe 
cool  portion  of  the  tube  in  octahedral  ciystals  of  arsenious 
oxide. 

Mention  the  physical  and  the  chemical  properties  of 
H^S. 

Hydrogen  sulphide  is  a  colorless  transparent  gas,  slightly 
heavier  than  air,  of  disagreeable  odor,  soluble  in  water.  It 
is  an  acid,  bui'ns  with  a  blue  flame,  pi"oducing  water  and  sul- 
phur dioxide.  Used  chiefly  as  a  reagent  for  the  precipitation 
of  certain  of  the  heavy  metals  from  their  solutions. 


12  CHEMISTRY. 

Give  the  symbol,  valence,  occurrence  in  nature,  physical 
properties  and  chemical  properties  of  one  of  the  follow= 
ing:  bromine,  silicon,  copper,  antimony,  manganese. 

Copper,  symbol,  Cu;  valence  II,  occurs  in  nature  in  the 
free  state  and  as  the  oxide  and  sulphide.  It  is  a  soft,  ductile, 
red  metal  with  a  specific  gravity  of  8.9,  atomic  weight  63.1. 
It  is  a  good  conductor  of  heat  and  electricity.  In  dry  air 
it  undergoes  no  change,  but  in  moist  air  it  gradually  becomes 
coated  with  a  film  of  the  basic  carbonate.  Heated  in  the  air 
it  oxidizes  to  CuO.  It  is  soluble  in  hot  mineral  acids,  and  is 
acted  upon  'by  many  of  the  vegetable  acids. 

Mention  the  halogens.  Why  are  they  so  called?  Give 
the  formulas  of  three  compounds  each  of  which  shall  con= 
tain  a  different  halogen. 

The  halogens  are  flourine,  chlorine,  bromine  and  iodine. 
The  name  is  derived  from  the  Greek,  meaning  "  salt  pro- 
ducer," and  was  given  because  of  the  saline  character  of 
many  of  the  compounds  of  these  elements. 

NaCl,  sodium  chloride;  KI,  potassium  iodide;  KBr,  potas- 
sium bromide. 

State  the  sources  of  ammonium  compounds.  Give  the 
composition,  the  method  of  preparation  and  the  properties 
of  sal-ammoniac. 

Ammonium  compounds  are  derived  from  the  ammoniaeal 
liquor  from  gas  works. 

Sal  ammoniac  is  the  chloride  of  ammonium,  made  by  satu- 
rating the  ammoniaeal  liquor  with  hydrochloric  acid,  evapo- 
rating the  solution  to  dryne^,  and  subliming  the  salt  pro- 
duced. It  is  a  white  crystalline  substance,  salty  in  taste, 
odorless,  very  soluble  in  water. 

Give  a  test  for  (a)  ferric  compounds,  (b)  ferrous  com- 
pounds. Write  the  chemical  names  and  the  formulas  of 
three  salts  of  iron  used  in  medicine. 

(a)   Potassium  ferrocyanide  gives  a  dark  blue  precipitate 


CHEMISTRY.  13 

(Prussian  blue),      (b)    Potassium  ferricyanide  gives  a  dark 
blue  precipitate  (Turnbull's  blue). 

Ferric  chloride,  FesClg  or  FeClg ;  ferrous  carbonate,  FeCO^ ; 
ferrous  sulphate,  FeS04. 

Give  the  history,  occurrence,  preparation,  properties 
and  medicinal  uses  of  chlorine. 

Discovered  by  Scheele  in  1774,  and  was  long  thought  to  be 
a  compound.  The  name  was  given  to  it  on  account  of  its 
color.  ^Occurs  in  nature  only  in  combination,  chief  com- 
pound, sodium  chloride  or  common  salt.  Prepared  by  the 
action  of  hydrochloric  acid  on  manganese  dioxide.  Proper- 
ties :  a  yellowish-green  suffocating  gas,  heavier  than  air,  solu- 
ble in  water.  Chemically  it  is  an  element,  symbol,  CI,  atomic 
weight  35.18,  a  monad  in  combining  power,  and  has  strong 
affinity  for  other  elements,  especially  for  hydrogen.  Chlorine 
is  us^ed  as  a  disinfectant  and  deodorant;  its  aqueous  solution 
has  been  used  locally  in  scarlet  fever,  diphtheria,  gangrene 
of  the  mouth,  etc. 

Hydrargyri  oxidum  flavum  may  be  prepared  by  pour= 
ing  a  solution  of  mercuric  chloride  into  a  solution  of 
sodium  hydrate;  give  the  chemical  equation. 

IIgCl2+2NaOH=HgO+2NaCl+H20. 

Mention  the  oxides  of  iron  and  give  the  formula  of  one 
of  them. 

Ferrous  oxide,  ferric  oxide,  and  ferro-ferric  or  magnetic 
oxide.     The  formula  for  ferric  oxide  is  FeoO,. 

Give  the  common  name,  formula,  properties,  prepara- 
tion and  uses  of  zinc  sulphate. 

White  vitriol,  ZnSO^,  made  by  dissolving  zinc  in  sulphuric 
acid  and  then  evaporating  the  solution.  A  white,  crystalline, 
freely  soluble  salt  with  metallic  taste.  It  is  used  as  an  emetic 
and  for  its  effects  upon  the  nervous  system,  in  chorea,  etc.. 
in  many  cutaneous  affections  in  ointment  form,  as  a  collyrium 
in  aqueous  solution,  and  also  for  injection  in  gonorrhoea. 


14  CHEMISTRY. 

Give  the  formula  and  method  of  manufacture  of  po= 
tassium  nitrate. 

KNO3.  Made  by  decomposition  of  sodium  nitrate  by  means 
of  potassium  carbonate  or  chloride. 

NaN03+KCl=NaCl+KN03. 

Give  the  symbol,  atomic  weight  and  valence  of  five  non= 
metals. 

Chlorine,  CI,  35.2  (35.18),  valence  I.  Oxygen,  0,  16 
(15.88),  valence  II.  Sulphur,  S,  32  (31.83),  valence  II., 
IV.,  VI.  Carbon,  C,  12  (11.91),  valence  II.,  IV.  Nitrogen, 
N,  14  (13.93),  valence  III.,  V. 

Define  amid,  anilid,  radical. 

An  amid  may  be  regarded  as  a  substance  formed  from  am- 
monia by  substituting  one  or  more  acid  radicals  for  one  or 
more  hydrogen  atoms. 

An  anilid  is  a  derivative  of  anilin,  formed  by  substituting 
acid  radicals  for  hydrogen. 

A  radical  is  an  atom  or  group  of  atoms  forming  the  basis 
of  a  series  of  compounds,  but  incapable  of  existing  in  the 
free  state. 

How  may  lead  enter  the  system  and  produce  chronic 
lead  poisoning?  Give  the  diagnosis  of  lead  poisoning  and 
mention  the  chemical  antidotes  for  it. 

Lead  may  be  introduced  into  the  system  by  the  drinking 
of  water  which  has  been  standing  in  lead  pipes;  with  food 
which  has  been  in  contact  with  the  metal  (tin-foil  containing 
lead,  lead  glaze  on  pottery,  etc.)  ;  by  handling  of  lead  com- 
pounds (manufacture  or  use  of  paints,  etc.)  ;  by  use  of 
hair  dye  containing  lead,  etc.  In  chronic  lead  poisoning  we 
have  anemia,  colic,  obstinate  constipation,  blue  line  on  the 
gums,  "  wrist-drop,"  and  palsy.  The  chemical  antidotes  are 
the  sulphates  of  sodium  and  magnesium,  dilute  sulphuric 
aicid.  etc. 

Mention  the  principal  products  obtained  from  petroleum 


CHEMISTRY.  15 

and  describe  the  properties  of  one  of  the  products  men= 
tioned. 

By  fractional  distillation  we  obtain  from  petroleum  the 
petroleum  ethers,  gasoline,  benzin,  the  napthas,  kerosene, 
lubricating  oils  and  paraffin. 

Benzin  or  benzinum  is  a  transparent  colorless  liquid  of 
characteristic  odor,  lighter  than  water,  insoluble  in  water, 
soluble  in  6  parts  alcohol,  and  freely  soluble  in  ether,  ben- 
zene and  oils.  Boils  at  45°  to  60°  C,  and  is  highly  inflam- 
mable. 

Describe  starch.  How  may  starch  be  recognized  chemi= 
cally?  What  substance  is  formed  when  diastase  or  dilute 
acids  act  on  starch? 

A  fine  white  powder  or  in  irregular,  angular  masses:  in- 
odorous and  tasteless,  insoluble  in  cold  water  or  alcohol, 
forming  a  paste  or  whitish  jelly  when  boiled  with  water.  It 
is  recognized  chemically  by  the  blue  color  with  iodine  test 
solution. 

By  the  action  of  diastase  starch  is  converted  into  maltose 
and  dextrin ;  by  the  action  of  dilute  acids,  into  dextrose  and 
dextrin. 

Describe  the  preparation  and  uses  of  gun  cotton 
(pyroxylin). 

Pyroxylin  is  made  by  steeping  cotton  in  a  mixture  of  nitric 
and  sulphuric  acids,  then  removing  and  washing  with  cold 
water.    It  is  used  in  making  collodium. 

How  is  collodion  prepared? 

Collodion  (collodium,  U.  S.  P.)  is  made  by  dissolving  py- 
roxylin in  ether  and  alcohol.  Four  grams  of  pyix)xyliu  with 
75  Co.  ether  are  allowed  to  stand  15  minutes  and  then  25  Cc. 
alcohol  are  added. 

What  is  vinegar  chemically?  Describe  the  chemical 
changes  in   the  manufacture  of  vinegar. 

Vinegar  is  a  dilute  (about  4  jyer  cent.)  ■solution  of  acetic 


16  CHEMISTRY. 

acid  with  traces  of  various  vegetable  extractives.  It  is  pro- 
duced by  the  oxidation  of  alcoholic  liquors,  wine,  cider,  etc., 
under  the  influence  of  the  acetic  acid  ferment,  mycoderma 
aceti. 

C2H,OH+02=HC,H303+H,0. 

What  is  the  chemical  treatment  of  alimentary  corrosion, 
caused  by  mineral  acids?  Why  should  the  stomach  pump 
be  used  carefully,  if  at  all,  in  such  cases? 

The  acid  should  be  neutralized  by  weak  alkalies,  preferably 
by  magnesia,  with  the  precaution  that  if  carbonates  are  used 
they  must  be  given  slowly  and  in  dilute  solution  to  avoid  a 
sudden  evolution  of  gas.  The  stomach-pump  must  be  used 
only  with  greatest  caution  on  account  of  danger  of  mechanic- 
ally injuring  the  corroded  membranes. 

Give  the  chemical  treatment  of  phosphorus  poisoning. 

Copper  sulphate  is  the  chemical  antidote.  An  attempt  is 
made,  also,  to  oxidize  the  phosphorus,  using  for  this  purpose 
hydrogen  dioxide,  ozone,  old  oil  of  turpentine,  etc. 

Give  the  formula  and  properties  of  methane  and  describe 
its  preparation. 

Methane,  CH^,  known  also  as  marsh  gas,  is  produced  in 
nature  by  the  decomposition  of  vegetable  matter  under  water. 
It  is  a  light,  colorless,  odorless,  tasteless,  inflammable  gas. 
Burns  with  a  bluish  flame  and  forms  an  explosive  mixture 
with  air.  It  may  be  prepared  by  heating  a  mixture  of  sodium 
acetate,  sodium  hydroxide  and  lime.  Representing  the  reac- 
tion as  taking  place  between  the  two  sodium  compounds,  we 
have 

NaCaHgO^+NaOH^^CH^+NaaCOs. 

What  is  an  alkaloid?  Mention  an  alkaloid  of  (a)  bella= 
donna,  (b)  cinchona,  (c)  hyoscyamus. 

An  alkaloid  may  be  described  as  an  organic,  nitrogenous 
substance,  basic  in  character,  capalble  of  combining  directly 
with  acids  to  form  salts. 

(a)  Atropine,  (b)  quinine,  (c)  hyoscy amine. 


CHEMISTRY.  17 

Differentiate  chemically  cane-sugar  and  grape='Sugar. 

Cane  sugar,  CigHoaOn,  does  not  reduce  FeMing's  solution; 
with  Ti'ommer's  test  a  blue  solution  is  obtained,  but  there  Is 
no  reduction  on  boiling. 

Grape  sugar,  CgHiaOe,  readily  reduces  both  Fehling's  and 
Trommer's  solutions. 

Give  the  symptoms,  diagnostic  features  and  treatment 
of  phosphorus  poisoning. 

Disagreeable  taste,  thirst,  nausea,  vomiting,  purging,  later 
a  jaundiced  condition  and  hemorrhages;  sometimes  neurotic 
symptoms,  cramps,  etc.  A  fatty  degeneration  of  the  organs 
is  produced.    Vomited  matter  may  be  luminous  in  the  dark. 

Treatment — Copper  sulphate  as  emetic  and  chemical  anti- 
dote, magnesium  sulphate,  animal  charcoal,  dilute  hydrogen 
dioxide,  old  oil  of  turpentine. 

Give  the  name,  properties  and  preparation  of  each  of 
the  following:  (a)  N.O  (b)  HNO3. 

Nitrous  oxide  or  nitrogen  monoxide,  NjO,  is  a  colorless, 
odorless  gas  with  faint  sweetish  taste,  used,  chiefly  in  den- 
tistry, as  an  anesthetic.  It  is  prepared  by  heating  ammonium 
nitrate. 

Nitric  acid,  IINO3,  is  a  colorless  fuming  liquid,  which  dis- 
solves many  metals,  and  acts  as  an  oxidizing  agent,  destroying 
animal  and  vegetable  tissue.  It  is  prepared  commercially  by 
the  action  of  sulphuric  acid  on  sodium  nitrate. 

Complete  the  following  equations: 

2AICl3+3H,0= 

HgCI,+2K()H=: 

In  the  first  equation  given,  adding  water  to  aluminum 
chloride,  we  merely  effect  a  solution. 

IIgCl2+2KOH=HgO+2KCl+H20. 
Complete  the  following  equations: 
MnO,+2KOH4-0= 
H3AsO^+H2S08= 

Mn02+2KOHH-0=K2Mn04+H20. 
H3AsO,4-H2SO,=H3AfiO,-fHjSO,. 
2 


18  CHEMISTRY. 

Mention  three  metallic  elements  that  occur  free  in  na= 
ture,  and  describe  one  of  them. 

Gold,  platinum  and  copper.  Copper  is  a  red,  soft,  ductile 
metal,  a  good  conductor  of  heat  and  electricity.  In  dry  air 
it  undergoes  no  change  hut  exposed  to  moisture  gradually 
becomes  coated  with  a  thin  layer  of  green  basic  carbonate. 
Heated  in  the  air  it  oxidizes. 

State  the  chemical  formula  of  (a)  lead  oxid  (b)  lead 
acetate,  (c)  lead  carbonate. 

Lead  oxide,  PbO.  Lead  acetate,  Pb(C2H302)2-  Lead  car- 
bonate, PbCOs- 

Give  the  symbol,  occurrence  in  nature,  properties,  uses, 
and  principal  compounds  of  argentum. 

Argentum,  Ag.  Silver  occurs  in  nature  cliiefly  combined 
with  chlorine  and  with  sulphur,  and  is  frequently  associated 
with  lead  oi^es. 

It  is  a  white  metal  with  a  sp.gr.  of  about  10.5,  malleable, 
soft,  ductile,  the  best  known  conductor  of  heat  and  electricity. 
It  does  not  oxidize  in  the  air  but  may  become  tarnished  from 
action  of  sulphides. 

Silver  is  used  in  making  silver  coins,  and  for  ornamental 
purposes.  In  the  form  of  colloidal  silver  it  is  used  as  a  germi- 
cide. 

The  prinoipial  eompounds  are  the  nitrate,  AgNOg ;  the  oxide, 
AggO ;  the  cyanide,  AgCN,  and  the  halogen  salts,  AgCl,  AgBr, 
Agl. 

What  is  the  usual  antidote  for  arsenic?  Give  the  chem= 
istry  of  the  action  when  an  antidote  for  arsenic  is  em= 
ployed. 

The  usual  antidote  for  arsenic  is  freshly  precipitated  ferric 
hydroxide.    The  reaction  is  as  follows : 

2Fe2(OH)e+As,03=Fe3(AsOj2+Fe(OH)2+5H20. 
An  insoluble  compound  of  iron  and  arsenic  is  thus  formed. 


CHEMISTRY.  19 

Give  the  symbol,  valence  and  atomic  weight  of  (a) 
nitrogen,  (b)  surphur,  (c)  phosphorus. 

Nitrogen,  N,  valence  III.  and  V.,  atomic  weight  13.93  (14). 
Sulphur,  S,  valence  II.  and  lY.,  atomic  weight  31.83  (32). 
Phosphorus,  P.  valence  III.  and  V.,  atomic  weight  30.77 

(31). 

Name  and  give  a  quick  method  for  preparing  the  anti  = 
dote  for  acute  arsenical  poisoning. 

The  antidote,  freshly  precipitated  ferric  hydroxide,  may  be 
quickly  prepared  by  adding  ammonium  hydroxide  or  sodium 
carbonate  to  an  aqueous  solution  of  ferric  chloride.  Filter 
through  a  handkerchief,  wash  with  water,  and  administer  the 
precipitate  in  teaspoonful  doses. 

What  is  the  usual  source  of  glycerine?  Give  the  prop= 
erties  and  the  formula  of  glycerine. 

Glycerine  is  prepared  from  fat,  as  a  by-product  in  the 
manufacture  of  soap  and  candles.  It  is  a  triatomic  alcohol 
with,  the  formula  C3H-,(OH)3,  an  odorless,  colorless  liquid 
%vith  a  sweetish  taste,  heavier  than  water,  soluble  in  water  and 
in  alcohol  and  absorbs  water  on  exposure  to  the  air. 

Mention  the  chief  elements  of  organic  compounds  and 
describe  the  preparation  and  the  characteristics  of  one  of 
the  elements  mentioned. 

The  chief  elements  of  organic  compounds  ai-e  carbon,  hy- 
drogen, nitrogen  and  oxygen. 

Hydrogen  may  be  made  by  decomposing  sulphuric  acid  by 
means  or  zinc.  Zn4-H2S04^ZnS04-|-H2.  It  is  a  colorless, 
transparent,  odorless,  ta.steless  gas,  fourteen  and  a  half  times 
lighter  than  air,  and  is  veiy  inflammable. 

What  are  carbohydrates?  Make  a  division  of  carbo- 
hydrates into  two  groups  and  state  the  differences  be- 
tween the  members  of  these  groups. 

The  carlK)hyd rates  are  compounds  of  carbon,  hydrogen  and 
oxygen,  the  last  two  being  in  the  proportion  in  which  they 


20  CHEMISTRY. 

are  found  in  water.    Chemically,  the  carbohydrates  are  allied 
to  the  hexatomic  alcohols. 

There  is  no  authentic  classification  into  two  groups,  the 
usual  one  being  into  three,  namely:  Monosaccharids  or  Glu- 
coses, Disaccharids  or  Sucroses,  and  Polysaoeharids  or  Amy- 
loses.  Other,  more  elaborate  classifications,  are  also  used. 
The  monosaccharids  differ  from  the  other  two  classes  in  the 
fact  that  upon  being  warmed  with  dilute  acids  they  do  not 
yield  any  other  sugar  or  sugars.  Possibly  a  classification  into 
two  groups  might  be  based  upon  this  difference. 

Define  alcohol.  Give  the  approximate  percentage  of 
alcohol  in  (a)  light  wines,  (b)  heavy  wines,  (c)  beers,  (d) 
whisky,  (e)  brandy. 

An  alcohol  may  be  defined  as  a  compound  of  a  hydrocarbon 
radical  with  hydroxyl,  e.  g.,  ordinary  alcohol,  C2H5OH, 

(a)  6  to  12  per  cent.,  (b)  12  to  25  per  cent.,  (e)  average  of 
4  to  5  per  cent.,  (d)  30  to  60  per  cent.,  (e)  30  to  50  per  cent., 
these  percentages  being  all  by  volume. 

In  a  thousand  parts  of  human  urine  what  will  be  the 
average  composition  as  to  (a)  water,  (b)  urea,  (c)  uric 
acid,  (d)  organic  matters,  (e)  chloride  of  sodium,  (f)  phos= 
phoric  acid,  (g)  potash  and  lime. 

(a)  In  1000  parts  by  weight  of  urine  there  will  be  about 
980  parts  water,  (b)  about  22  parts,  (c)  0.4  part,  (d)  25 
parts,  (e)  8  parts,  (f)  2  parts  (P2O5),  (g)  potash,  2  parts 
(K2O),  and  lime,  0.2  part. 

(The  above  is  a  most  unusual  form  of  stating  urinary  com- 
position.) 

How  is  chloroform  (a)  prepared,  (b)  purified,  (c)  tested 
for  impurities? 

(a)  Chloroform  may  be  prepared  by  the  action  of  bleaching 
powder  on  alcohol,  or  on  acetone,  or  by  the  action  of  an  alkali 
on  chloral,  (b)  It  is  purified  by  shaking  with  water  and  then 
with  pure  sulphuric  acid;  it  is  then  agitated  with  lime  and 
with  diy   calcium  chloride,   and  finally   redistilled,     (c)    It 


CHEMISTRY.  21 

should  yield  no  foreign  odor  on  evaporation.  Shaken  with 
water,  the  latter  should  be  neutral  to  litmus,  and  should  not 
he  affected  by  addition  of  silver  nitrate  or  of  potassium  iodide. 
Shaken  with  one-tenth  part  strong  sulphuric  acid,  the  chloro- 
form should  remain  colorless  and  the  acid  should  not  he  more 
than  faintly  colored. 

What  is  the  range  of  the  specific  gravity  of  normal 
urine?  State  what  diseased  conditions  produce  (a)  an  ab^* 
normally  high  specific  gravity  of  the  urine,  (b)  a  low 
specific  gravity  of  the  urine. 

The  specific  gravity  varies  generally  between  1010  and  1030, 
Avith  an  average  of  1020. 

(a)  Diabetes  mellitus,  acute  nephritis,  fever,  loss  of  water 
by  other  excretions.  (b)  Interstitial  nephritis,  uremia, 
chronic  parenchymatous  nephritis,  absorption  of  exudates,  etc. 

How  is  carbolic  acid  prepared?  Give  the  treatment  of 
carbolic  acid  poisoning. 

Carbolic  acid  or  phenol  is  prepared  from  coal-tar  by  frac- 
tional distillation  with  subsequent  purification,  or  it  is  pre- 
pared synthetically  from  benzene. 

Treatment. — Use  stomach  tube  cautiously,  chemical  anti- 
dotes are  sodium  sulphate,  magnesium  sulphate,  dilute  acetic 
acid  (vinegar),  and  strong  alcoholic  drinks.  Keep  body  warm 
and  give  stimulants. 

Mention  a  secretion  of  the  body  that  contains  (a) 
cholesterin,  (b)  pepsin,  (c)  trypsin,  (d)  casein,  (e) 
bilirubin. 

(a)  Bile,  (b)  gastric  juice,  (c)  pancreatic  juice,  (d)  milk 
(caseinogen),  (e)  bile. 

What  reaction  takes  place  when  chloral  hydrate  is 
mixed  with  an  alkali?     Illustrate. 

Chloroform  is  produced. 

Chloral,  CCl3COII4-NaOH=chloroform.  CHClg-j-sodium 
formate.  NaCOOH. 


22  CHEMISTRY. 

Give  the  chemical  reaction  of  (a)  saliva,  (b)  gastric 
juice,  (c)  tears,  (d)  bile,  (e)  blood. 

(a)  Alkaline,  (b)  aoid,  (c)  neutral,  (d)  alkaline,  (e)  alka- 
line. 

Give  the  chemistry  of  acetic  acid;  mention  the  most  im= 
portant  acetates  and  give  a  method  of  preparing  one  of 
them. 

Acetic  acid,  HC2H3O2,  is  prepared  by  the  destructive  dis- 
tillation of  wood  and  also  by  the  oxidation  of  alcohol.  It  is 
a  clear,  colorless  liquid  with  characteristic  odor. 

Important  acetates  are  acetate  of  ammonium,  iron  and 
ammonium,  lead,  potassium,  sodium  and  zinc.  Potassium 
acetate  is  made  by  neutralizing  iaoetic  acid  with  potassium 
caribonate. 

Give  the  formula  of  (a)  common  (ethyl)  alcohol,  (b) 
sulphuric  ether,  (c)  acetic  acid. 

(a)  C^H.OH.     (b)   (CA)20.     (c)  HC2H3O2. 

State  the  non=pathologic  causes  of  abnormal  deviations 
in  the  urinary  specific  gravity. 

The  specific  gravity  may  be  increased  above  the  normal 
average  by  sleep,  by  exercise,  by  perspiration;  it  may  be  de- 
creased by  drinking  of  large  quantities  of  liquids,  by  check- 
ing of  perspiration,  by  chilling  the  surface  of  the  body,  etc. 

What  are  (a)  albuminoids,  (b)  proteids?  Give  ex= 
amples  of  each. 

(a)  Albuminoids  are  substances  of  modified  proteid  nature 
charaoteristic  of  the  supporting  tissues  of  the  body,  e.g.. 
ossein,  chondrigen,  elastin. 

(b)  The  term  proteid  is  variously  used  (1)  to  signify  the 
entire  class  of  carbon,  nitrogen,  hydrogen,  oxygen  and  sul- 
phur compounds  which  on  decomposition  yield  ammonium 
compounds,  amides,  amido  acids,  etc.,  including  the  albumins 
and  globulins,  the  derived  substances,  peptone,  etc.,  the  com- 
pound protein  substances,  mucin,  hemoglobin,  etc.,  and  the 


CHEMISTRY.  23 

albuminoids.  (2)  It  is  sometimes  used  to  represent  the  albu- 
mins and  the  derived  and  compound  albumins,  excluding  the 
albuminoids.  (3)  It  is  sometimes  used  to  represent  the  com- 
pound albumins  alone,  mucin,  hemoglobin,  etc. 

Mention  four  alkaloids  of  opium. 

Morphine,  narcotine,  papaverine  and  codeine. 

What  is  the  source  of  uric  acid  in  the  economy?  Give 
the  formula  and  properties  of  uric  acid  and  mention  its 
chemical  tests. 

Uric  acid  is  derived  in  part  from  the  nucleins  of  the  body 
tissues  and  in  part  from  similar  bodies  taken  in  food.  It 
has  the  formula  C^.H^N^Og,  and,  when  pure,  is  a  colorless, 
crystalline,  odorless,  tasteless  powder,  very  insoluble  in  cold 
water  and  in  most  acids,  in  alcohol  or  in  ether.  Soluble  in 
sulphuric  acid  and  in  solutions  of  many  of  the  alkaline  salts. 

The  murexid  test. — Moisten  with  nitric  acid,  evaporate  to 
dryness,  moisten  the  residue  with  ammonium  hydroxide — a 
purple- red  color  is  obtained.  The  silver  carbonate  test. — 
Render  the  urine  alkaline  with  sodium  carbonate,  moisten  a 
filter  paper  Adth  the  liquid  and  touch  the  moist  paper  with 
a  glass  rod  carrying  a  drop  of  silver  nitrate.  A  gray  stain 
indicates  presence  of  uric  acid. 

How  do  human  milk  and  cow's  milk  differ?  What 
chemical  changes  take  place  in  milk  when  it  is  exposed  to 
atmospheric  influences. 

Human  milk  contains  rather  less  total  solids,  less  proteids, 
more  sugar,  and  less  salts  than  cow's  milk.  The  fat  is  about 
the  same. 

On  exposure  to  air,  bacteria  are  taken  up  by  the  milk,  and, 
under  the  influence  of  the  bacterium  lactis,  lactose  is  changed 
to  lactic  acid.  This  produces  a  separation  of  a  precipitate 
of  caseinogen  (curd).  As  a  result  of  further  decomposition 
the  lactic  acid  is  changed  to  butyric  acid  which  may  be  recog- 
nized by  its  odor. 


24  CHEMISTRY. 

State  the  general  composition  of  fats  and  give  the  chief 
constituents  of  (a)  tallow,  (b)  butter,  (c)  olive  oil. 

Fats  are  compounds  of  the  radical  glyceryl  (C3H5)  with 
the  higher  acids  of  the  first  and  second  series  of  hydrocar'bons ; 
most  abundantly  we  find  the  glycerides  of  palmitic,  stearic 
and  oleic  acids. 

(a)  Tallow  is  characterized  chiefly  by  stearin,  the  glyceride 
of  stearic  acid;  (b)  butter  is  characterized  by  a  larger  per- 
centage of  the  glycerides  of  the  more  volatile  acids,  butyric, 
caproic,  caprylic,  etc. ;  (c)  olive  oil  is  a  glyceride  of  oleic  and 
palmitic  acids  with  arachnidin  and  cholesterol. 

Give  the  composition  and  properties  of  urea. 

Urea,  C0(NH2)2,  is  the  chief  nitrogenous  excrement  of 
mammals.  It  is  a  crystalline  substance  very  soluble  in  water, 
less  soluble  in  alcohol,  insoluble  in  ether. 

What  is  the  usual  composition  of  urinary  calculi?  Give 
the  test  for  recognizing  the  principal  ingredient. 

Uric  acid  and  urates,  calcium,  magnesium  and  ammonium 
phosphates,  and  calcium  oxalate.  Uric  acid  is  frequently  the 
nucleus  about  which  a  calculus  builds  itself,  and  may  there- 
fore be  regarded  as  "  the  principal  ingredient."  The  test 
for  uric  acid  is  the  murexid  test:  Evaporate  with  a  drop  of 
nitric  acid  and  moisten  the  residue  with  ammonium  hydroxide. 
A  purple-red  color  indicates  uric  acid  (or  urates). 

What  chemical  reaction  takes  place  when  H2O2  is  ap= 
plied  to  sloughing  wounds? 

It  acts  as  an  oxidizing  agent,  giving  off  an  atom  of  nascent 
oxygen  which  attacks  dead  tissues,  pus,  etc.  The  decomposi- 
tion of  the  hydrogen  dioxide  is  accompanied  by  effervescence. 

What  is  hemoglobin?  Name  some  of  its  properties  and 
give  a  chemical  test  for  it. 

Hemoglobin  is  a  compound  of  an  iron-holding  radical, 
hemochromogen  (hematin),  with  an  albuminous  radical, 
globin.     To  it  the  blood  owes  its  color.     It  combines  readily 


CHEMISTRY.  25 

with  oxygen,  forming  oxyhemoglobin,  by  which  oxygen  is 
carried  to  the  tissues.  Various  derivatives  of  hemoglobin  may 
be  produced  by  action  of  reducing  agents,  etc.,  and  many  of 
the  body  pigments  are  derived  therefrom.  Hemoglobin  may 
be  recognized  by  the  guaiacum  test:  To  the  fluid  add  3-4 
drops  of  freshly  prepared  tincture  of  guaiacum  resin;  float 
an  etherial  solution  of  hydrogen  dioxide  on  the  surface  of  the 
mixture — ^in  presence  of  hemoglobin  a  blue  color  will  develop. 
Or  the  ' '  hemin  ' '  test  may  be  used :  To  a  drop  of  blood  on  a 
glass  slide  add  a  minute  crystal  of  sodium  chloride  and  two 
drops  of  glacial  acetic  acid  and  heat  slowly  to  boiling.  Cool 
and  examine  under  the  microscope  for  crystals  of  hematin 
hydrochloride. 

When  testing  for  albumin  in  urine,  how  do  you  deter= 
mine  between  it  and  other  coagulable  proteids? 

The  only  proteids  coagulated  by  heat  are  albumin  and 
globulin;  of  these  albumin  is  soluble  in  pure  water;  globulin 
is  not.  Add  the  urine  drop  by  drop  to  some  clear  water  in 
a  test-tube;  if  globulin  be  present  a  cloud  will  form  as  each 
drop  sinks  through  the  water.  Globulin  may  be  separated 
from  albumin  by  saturation  with  magnesium  sulphate;  glo- 
bulin is  precipitated,  albumin  is  not. 

When  testing  for  glycosuria  with  Fehling's  solution 
how  do  you  determine  whether  the  reaction  is  that  of 
sugar  or  some  other  reducing  agent? 

By  applying  the  fermentation  test  with  yeast,  the  glucose 
of  diabetic  urine  ferments  readily,  while  glycuronic  acid  and 
other  reducing  substances  which  may  be  present  do  not  fer- 
ment. 

State  the  conditions  favorable  to  crystallization. 

That  the  molecules  shall  be  free  to  move,  as  they  are  when 
tJie  substance  is  in  fluid  condition.  The  substance  is  melted 
and  slowly  cooled,  or  dissolved  in  a  suitable  solvent  and  then 
slowly  evaporated. 


26  CHEMISTRY. 

What  temperature  Fahrenheit  is  equivalent  to  a  tem- 
perature of  28  degrees  Centigrade?  What  temperature 
Centigrade  is  equivalent  to  a  temperature  of  120  degrees 
Fahrenheit? 

28  degrees  C.  X  Vs  ==  50.4  plus  32  equals  82.4  Fahr. 
120  degrees  Fahrenheit  minus  32  equals  88   X  ^/g  equals 
48.8  C. 

Define  atom,  molecule. 

The  atom  is  the  smallest  particle  into  which  matter  can  be 
divided. 

A  molecule  is  the  smallest  particle  into  which  matter  can 
he  divided  without  altering  its  characteristic  properties. 

Give  the  names  of  two  elements  or  radicals  in  each  of 
the  following  groups: 

Univalent.       Bivalent.       Trivalent.  Quadrivalent. 

Hydrogen.         Oxygen.                     Boron.  Carbon. 

Chlorine.            Sulphate  SO4.           Aurum.  Platinum. 

Illustrate  the  comparative  significance  of  the  following 
afHxes:  ous,  ic,  ite,  ate,  id. 

An  oxy-acid  of  stable  composition,  or  one  of  great  import- 
ance to  arts  and  industries,  takes  the  termination  ic,  as  HgSO^, 
sulphuric  acid. 

If  an  oxy-acid  of  the  same  elements  contains  less  oxygen  in 
its  molecule  it  terminates  in  ous,  as  H2SO3,  sulphurous  acid. 

The  terminations  ous  and  ic  may  be  used  also  to  distinguish 
between  different  combinations  (not  acid)  of  the  same  ele- 
ments, the  ous  indicating  the  lower  valence  (real  or  apparent) 
of  the  positive  element,  e.  g.,  ferrous  sulphate,  FeS04 ;  ferric 
sulphate,  Fe2(  804)3. 

Salts  formed  by  replacing  the  hydrogen  of  an  ic  acid  by  a 
metal  or  basic  radical  have  their  names  terminating  in  ate, 
as  ZnS04,  zinc  sulphate. 

Salts  formed  by  repla<;ing  the  hydrogen  of  an  ous  acid  have 
their  names  ending  in  ite,  ^as  NagSOg,  sodium  sulphite. 

Salts  of  hydracids  have  the  termination  id  (or  ide) . 


CHEMISTRY.  27 

Compare  ozone  with  oxygen  as  to  (a)  occurrence,  (b) 
properties. 

(a)  Ozone  is  found  in  air  only  under  exceptional  cireum- 
stanees,  or* in  minute  quantities. 

Oxygen  occurs  in  all  atmospheric  air  in  the  proportion  of 
about  23  i)er  cent,  by  weight. 

(b)  Ozone  is  a  very  energetic  oxidizing  agent,  acting  like 
nascent  oxygen,  and  oxidizing  substances  that  resist  the  action 
of  ordinary  oxygen,  as  silver. 

Ozone  will  not  support  respiration,  acting  as  an  irritant  to 
respiratory  membranes. 

Ozone  supports  combustion  more  vigorously  than  oxygen. 

State  the  characteristics  of  the  following  mineral 
waters:  Chalybeate  waters,  bitter  waters,  sulphur  waters, 
effervescent  waters,  cathartic  waters. 

A  chalybeate  water  is  a  mineral  water  containing  dissolved 
salts  of  iron,  usually  basic  carbonates.  It  has  a  slight  tonic 
action,  but  may  occasion  intestinal  and  stomach  disturbance 
from  its  irritant  action. 

Bitter  waters  may  owe  their  bitter  properties  to  Epsom 
or  Glauber's  salts,  held  in  solution,  when  they  exert  a  laxa- 
tive action ;  or  a  natural  water  may  'be  bitter  from  its  contact 
with  vegetable  substances,  acquiring  thereby  tonic  and  stom- 
achic properties. 

Sulphur  waters  are  those  containing  dissolved  alkaline  sul- 
phides, or  poly-sulphides,  or  HjS.  Such  waters  exert  an 
alterative  and  often  slightly  laxative  effect,  and  have  a  certain 
value  in  treating  diseases  of  the  skin.  The  greater  value  of 
s-ulphur  waters  is  found  in  their  use  for  bathing,  in  chronic 
cutaneous  affections,  in  gout,  in  rheumatism. 

Effervescent  waters  are  such  as  are  strongly  charged  with 
CO,  gas.  Such  waiters  are  useful  as  sedative  and  slightly 
stimulating  beverages,  e.  g.,  the  use  of  plain  soda  water  in 
allaying  vomiting. 

Cathartic  watere  are  such  as  contain  cathartic  or  laxativ»> 
salts  in  solution,  e.  g..  Epsom  salts,  magnesium  sulphate*,  and 


28  CHEMISTRY. 

Glau^ber's  salts,  sodium  sulphate.  Their  effect  is  not  only 
that  of  a  cathartic,  they  may  assist  elimination  from  other 
channels,  as  kidneys,  skin,  etc. 

What  is  the  antidote  for  nitric  acid  poisoning? 

Oxide  of  magnesium,  commonly  eailed  calcined  magnesia. 
Alkaline  carbonates,  soap,  albumin,  oils. 

Describe  the  preparation  of  iodide  of  potassium.  Give 
the  reaction. 

Saturate  a  strong  solution  of  caustic  potash  in  water  with 
iodine.  Evaporate  to  dryness — a  mixture  of  iodide  and 
iodate  of  potassium  is  formed,  and  when  this  is  heated 
the  iodate  of  potassium  parts  with  its  oxygen.  Dissolve  the 
resultant  mass  in  water,  and  from  it  will  crystallize,  on 
evaporation,  cubes  of  potassium  iodide. 

6KHO+3l2=5KI+KI03+3H20 ; 

Then  2KI03+heal^2KI+302. 

Describe  lithium  as  to  (a)  occurrence,  (b)  salts  com=> 
monly  used  in  medicine,  (c)  chemistry  of  its  use  in  so= 
called  rheumatic  affections. 

(a)  Lithium  occurs  in  the  mineral  silicates  and  phosphates, 
and  as  chloride  and  carbonate  in  mineral  waters,  (b)  Salts 
used  in  medicine: 

Bromide  of  lithium  LiBr  Carbonate  of  lithium  LijCOj 

Benzoate  of  lithium  LiC^HjO.^  Citrate  of  lithium  Li3C5H507 

Salicylate  of  lithium  LiC^HjOj 

(c)  It  is  stated  that  25  parts  of  carbonate  of  lithium  will 
dissolve  one  thousand  parts  uric  acid  at  100.4°  Fahr. ;  it  is 
administered,  therefore,  in  gout  to  diminish  deposits  of  uric 
acid,  and  to  dissolve  uric  acid  calculi. 

Mention  the  important  physical,  physiologic  and  chem= 
ical  properties  of  ptomains. 

Ptomains  are  alkaloidal  substances  produced  by  the  action 
of  bacteria  on   decomposing  animal   and   vegetable  matter. 


CHEMISTRY.  29 

They  resemble  the  vegetable  alkaloids  in  composition,  and 
in  their  tests,  are  basic  in  character,  and  like  alkaloids  may  be 
poisonous  or  non-poisonous. 

In  their  poisonous  action,  after  a  period  of  from  two  to  six 
hours,  there  is  produced  severe  gastro-intestinal  irritation 
with  great  prostration. 

What  are  the  chemical  constituents  of  normal  urine? 
Give  a  test  for  the  recognition  of  albumin  in  urine. 

Chlorides  of  calcium,  magnesium,  sodium,  potassium. 
Phosphates  of  calcium,  magnesium,  sodium,  potassium.  Sul- 
phates of  sodium,  potassium  and  organic  sulphates,  indican, 
etc.  Coloring  matters,  including  urobilin,  urochrome,  uro- 
erythrin.  Urea,  uric  acid  (as  urates),  creatinine,  hippurdc 
acid. 

Boil  the  urine;  if  it  becomes  hazy,  or  a  coagulum  forms, 
add  a  few  drops  of  nitric  acid,  when,  if  the  urine  does  not 
become  perfectly  transparent,  albumin  is  present. 

State  the  principle  underlying  the  use  of  antitoxins  for 
the  prevention  or  cure  of  disease. 

Antitoxins  are  found  in  the  blood  serum  of  animals  that 
have  recovered  from  an  infectious  disease,  and  when  this 
serum  is  injected  into  other  animals,  or  mEin,  it  confers,  on 
its  absorption,  immunity  from  that  disease. 

How  may  water  be  decomposed?     Illustrate. 

By  passing  a  current  of  galvanic  electricity  through  water, 
when  the  hydrogen  gas  collects  in  bubbles  at  the  negative 
electrode  and  the  oxygen  gas  at  the  positive  electrode ;  or  by 
passing  steam  through  an  iron  pipe  heated  to  redness,  when  the 
hydrogen  gas  issues  at  the  distal  end  of  the  pipe  and  oxygen 
is  retained  in  chemical  union  with  the  iron,  coating  the  pipe 
with  FcgO^. 

Define  and  give  examples  of  the  three  varieties  of 
attraction. 

Attraction  of   gravitation  is  the   force  operating  between 


# 


30  CHEMISTRY. 

masses  of  matter,  e.  g.,  the  attractive  force  of  the  earth  for 
objects  upon  its  surface. 

Heterogeneous  attraction  or  adhesion  refers  to  surface  at- 
traction of  unlike  substances ;  thus  water  adheres  to  wood. 

Homogeneous  attraction  or  cohesion  is  the  force  uniting 
like  substances,  and  operates  in  the  interior  of  the  mass  as 
well  as  at  the  surface;  thus  cohesion  aggregates  the  mole- 
cules of  water  into  visible  drops. 

How  many  grams  are  there  in  a  hectogram?  How 
many  scruples  are  contained  in  one  pound? 

One  hundred  grams  equal  one  hectogram. 
Two  hundred  and  eighty-eight  (288)   scruples  one  pound 
troy. 

What  is  the  test  for  the  presence  of  silver,  of  mercury? 

In  solution :  Silver  with  hydrochloric  acid  or  with  soluble 
chlorides  yields  a  white  precipitate,  soluble  in  ammonium 
hydroxide,  insoluble  in  nitric  acid. 

Mercury  as  mercurosum,  in  solution,  gives  a  white  precipi- 
tate with  hydrochloric  acid,  of  mercurous  chloride,  not  dis- 
solving, hut  turned  black  on  addition  of  ammonium  hydroxide. 

Mercury  as  mercuricum,  gives  no  precipitate  with  hydro- 
chloric acid,  but  gives  a  white  precipitate  with  ammonium 
hydroxide  and  a  scarlet  precipitate  with  potassium  iodide. 

How  much  water  vapor  will  be  formed  by  the  union  of 
500  cubic  centimeters  of  hydrogen  and  250  cubic  centi= 
meters  of  oxygen? 

Five  hundred  cubic  centimeters,  at  standard  temperature 
and  pressure. 

What  is  a  graphic  formula?     Give  five  illustrations. 

A  graphic  formula  is  one  showing  something  of  the  manner 
in  which  the  atoms  are  joined  or  arranged  within  the  molecule. 


CHEMISTRY.  31 

H        O 

I       // 

Acetic  acid.     H— C — C — ( ) — H 

I 
H 

H— ()— H     Water.  H— S— H     Hydrogen  sulphide. 

H 


NE 


Ammonia.       11 C H     Marsh  gas. 

k 


Give  the  atomic  weight,  atomic  volume,  molecular 
weight,  molecular  volume,  and  density  of  oxygen. 

Atomic  weight,  16  (15.88);  atomic  volume,  1;  molecular 
weight,  32;  molecular  volume,  2;  specific  gravity  compared 
with  air,  1.1056;  specific  gravity,  or  density,  compared  with 
hydrogen,  15.88. 

Describe  the  preparation  of  sulphur  and  name  the 
oxides  of  sulphur. 

Prepai-ed  generally  from  the  native  crude  sulphur  found 
in  volcanic  regions,  by  subliming  from  the  non-volatile  im- 
purities. 

The  oxides  are  the  dioxide.  SO2,  the  trioxide,  SO3,  the  ses- 
quioxide,  S2O3,  and  the  peroxide,  S.O;. 

What  is  Marsh's  test?  Describe  the  apparatus  em- 
ployed, and  give  the  conduct  of  the  experiment. 

Test  for  detection  of  arsenic. 

Through  the  stopper  of  a  glass  flask  pass : 

1.  A  safety  funnel,  the  lower  end  reaching  to  bottom  of 
fla.sk. 

2.  An  outlet  tube  of  glass.  To  this  is  to  be  fitt-ed  (a)  a 
tube  bent  at  right  angle,  lower  part  dipping  into  a  solution 
of  AgNOj.  (b)  A  tube  bent  ai  right  angle  so  placed  that 
the  far  part  of  the  tube,  drawn  out  to  a  jet,  shall  point 
upwards. 

Test :  Place  chemically  pure  zinc  in  flask,  cover  with  dilute 
sulphuric  acid.  C.  P..  in  such  cpvantity  a.s  will  come  above 
l(»wer  end  of  safetv  funnel. 


32  CHEMISTRY. 

Hydrogen  gas  is  evolved.  Allow  gas  to  pass  from  the  out- 
let tube,  to  which  attach  tube  (a),  the  lower  end  of  which  is 
immersed  in  nitrate  of  silver  solution. 

Heat  the  outlet  tube  at  a  point  between  flask  and  silver 
solution.  At  expiration  of  half  hour  should  there  be  no  brown 
or  gray-black  stain  found  on  outlet  tube  where  heated,  or  no 
precipitate  (black)  found  in  silver  solution,  and  no  yellow 
precipitate  formed  when  to  a  little  or  silver  solution  is  added 
ammonium  hydroxide,  the  zinc  and  acid  used  are  free  from 
arsenic. 

Pour  into  safety  funnel  the  solution  suspected  to  contain 
arsenic,  when,  should  arsenic  be  present,  a  black  stain  forms 
on  outlet  tube,  a  black  precipitate  appears  in  silver  solution, 
and  this  solution  yields  yellow  precipitate  of  arsenite  of  silver 
when  to  it  we  add  ammonium  hydroxide. 

Now  substitute  tube  (b)  for  tube  (a)  ;  ignite  the  gas,  a 
whitish  flame  appears ;  if  much  arsenic,  a  garlic  odor  or  white 
halo  surrounds  flame. 

Hold  cold  white  surface,  as  piece  of  porcelain,  in  flame — a 
brown  or  black  stain  of  metallic  character  readily  dissolving 
in  solution  of  chlorinated  lime  or  chlorinated  soda,  indicates 
presence  of  arsenic. 

What  is  defiant  gas?    Name  some  of  its  properties. 

Olefiant  gas,  or  ethylene,  CoH^,  heavy  earburetted  hydrogen. 

A  colorless  gas,  feebly  ethereal,  slightly  pungent  odor,  den- 
sity 4  compared  with  hydrogen.     Almost  insoluble  in  water. 

Can  be  liquefied,  and  is  then  used  to  produce  low  tempera- 
ture on  its  evaporation.  Is  inflammable,  burning  in  air  with 
brilliant  flame,  forms  an  explosive  mixture  with  air  or  oxygen. 
It  is  largely  to  the  presence  of  this  gas  that  illuminating  gas 
yields  light. 

What  is  meant  by  the  destructive  distillation  of  wood, 
and  what  are  some  of  the  principal  products  of  such  a 
process? 

Heating  wood  in  a  retort  in  absence  of  air  and  collecting 
and  condensing  the  resultant  vapors. 


CHEMISTRY.  33 

Methyl  alcohol,  pyroligneous  acid,  acetic  acid,  creosote, 
carbolic  acid,  etc. 

Name  and  differentiate  the  three  classes  of  sugars. 

Monosaccharids  or  glucoses,  with  the  formula,  CgHijOg; 
disaccharids  or  sucroses,  CigHgaOn ;  polysaccharids  or  amy- 
loses,  (CeHioOs)^.  Chemically  the  glucoses  are  aldehydes 
and  ketones,  the  amyloses  and  sucroses  are  anhydrides  of  the 
glucoses. 

What  is  acetous  fermentation? 

Brought  a;bout  by  presence  of  the  mycoderma  aceti,  it  causes 
the  souring  of  alcoholic  liquors.  It  practically  consists  in  the 
oxidation  of  alcohol,  producing  acetic  acid. 

How  are  chlorides  chemically  recognized  in  urinalysis? 

By  their  yielding  a  white  precipitate  of  chloride  of  silver 
on  the  addition  of  a  solution  of  silver  nitrate  to  the  urine 
after  acidifying  \Adth  nitric  acid. 

Complete   the   following   equation   and   write   the    name 
of  each  resulting  compound  under  its  formula: 
C^HCKO+NaOH^ 

C2HCl30+NaOn=CHCl8+NaCn02 

Chloral.  Chloroform     sodium  formate. 

Pb(NO,)2+KXrO,= 

Pb  r  NO3)  ,+K2CrO,=PbOrO,+2KN03 

Lead  cliromate     potassium  nitrate. 
Describe    two   experiments  showing   the   difference   be- 
tween chemical  and  mechanical  action. 

Mix  32  grains  sulphur  and  56  grains  of  filings;  a  magnet 
will  remove  all  of  the  iron,  or  carbon  disulphide  vdU  dis- 
solve all  of  the  sulphur.  This  mixing  of  sulphur  and  iron  is  a 
mechanical  act,  in  which  iron  and  sulphur  still  preserve  their 
properties.  Apply  heat  to  such  a  mixture;  a  temperature 
much  higher  than  the  degrvc  of  heat  applied  will  develop,  due 
to  chemical  union  of  sulphur  and  iron,  and  a  magnet  will  no 
3 


34  CHEMISTEY. 

longer  attract  the  iron,  nor  will  carbon  disulphide  have  solvent 
action.  This  is  a  chemical  action  resulting  in  formation  of 
a  new  substance,  iron  sulphide,  in  which  the  properties  of  iron 
and  sulphur  no  longer  exist. 

Dissolve  sugar  in  water.  No  heat  is  evolved;  each  drop  of 
water  shows  characteristic  sweetness  of  sugar;  has  been  no 
chemical  change,  but  a  physical  or  mechanical  one.  Dissolve 
sugar  in  sulphuric  acid,  obtain  black  liquid  containing  no 
characteristic  sweetness ;  sugar  has  entirely  disappeared.  This 
experiment  is  an  illustration  of  chemical  action. 

If  potassium  be  thrown  on  water,  what  is  the  name  and 
formula  of  the  resulting  compound? 

Potassium  hydroxide,  KOH. 

What  are  the  general  methods  by  which  crystals  may 
be  obtained? 

Evaporation  from  solution,  solidification  after  fusion,  and 

by  sublimation- 
Discuss   arsenic   and    mention    its   properties,    uses   and 

compounds. 

Arsenic,  symbol  As,  atomic  weight  74.4,  valence  III.,  V., 
found  in  nature  chiefly  as  sulphide,  associated  with  the  sul- 
phides of  zinc,  iron,  bismuth,  etc.  The  metal  is  steel-gray, 
generally  crystalline,  with  a  metallic  luster.  Used  in  pyro- 
techny,  in  making  shot,  and  in  pigments. 

Forms  a  compound  v^dth  hydrogen,  AsHg,  a  very  poisonous 
gas.  With  oxygen  it  forms  the  trioxide,  AsgOg,  and  the 
pentoxide,  AsgOg,  the  first  named  being  the  most  important 
compound,  often  receiving  the  name  of  arsenic.  It  occurs  in 
a  heavy  white  powder,  or  transparent  vitreous,  or  opaque, 
porcelain-like  masses  slightly  soluble  in  water. 

Other  compounds  recognized  by  the  pharmacopceia  are  the 
iodide,  sodium  arsenate,  and  potassium  arsenite,  the  latter 
being  a  constituent  of  Fowler's  solution. 

The  arsenical  compounds  are  used  as  alterative  tonics  in 
phthisis,  malarial  cachexia,  cancer  pastes,  skin  diseases,  in 
dentistry,  etc. 


'  r   ' 

V 

CHEMISTRY.  35 

What  is  an  anesthetic? 

A  substance  used  to  produce  partial  or  complete  uncon- 
sciousness, and  thus  allay  pain  of  operative  procedures  and 
produce  muscular  relaxation. 

How  much  water  would  be  required  to  yield  loo  grams 
of  hydrogen? 

Nine  hundred  grams  of  water  would  yield  100  grams  hy- 
drogen. 

Compare  the  physical  properties  of  chlorine,  bromine, 
iodine  and  fluorine. 

Chlorine,  a  heavy  green  gas;  bromine,  a  heavy  dark  red 
volatile  liquid;  iodine,  scale-like  blue-black  volatile  solid; 
fluorine,  a  light  yellow,  practically  colorless,  gas. 

All  dissolve  in  water  in  varying  degrees.  Bromine  yields 
orange-colored  vapor;  iodine,  violet  vapor. 

Define  evaporation,  filtration. 

Evaporation  is  the  conversion  of  a  volatile  liquid  into  a 
vapor.     This  process  takes  place  at  all  temperatures. 

Filtration  is  the  act  of  passing  a  liquid  through  a  porous 
material,  the  solid  suspended  matters  being  retained. 

Name  the  constituents  of  the  atmosphere.  Give  the 
composition  by  weight  and  by  volume. 

Weight.  Volume. 

Oxygen 23  20.93 

Nitrogen 77  79.07 

Water  vapor,  .5  to  1.4.    Carbon  dioxide,  .04. 

Traces  of  ammonia  and  other  nitrogen  compounds. 

Several  rare  gases,  argon,  etc. 

Name  bodily  conditions  effecting  an  increase  in  the 
elimination  of  urine  and  also  those  producing  a  decrease. 

In  health  urine  is  increased  in  amount  when  from  any 
cause  the  perspiratory  function  or  alvine  discharges  are  less- 
ened, as  from  chill  of  the  surface,  cold  bathing,  etc.  The 
ingestion  of  much  fluid,  as  drink  or  watery  foods.  In  health 
urdne  is  decreased  by  excessive  perspiration,  diarrha?a,  etc. 


36  CHEMISTRY. 

In  disease  urine  is  increased  in  diabetes  mellitus,  in  chronic 
inflammation  of  kidneys,  etc.  Often  at  crisis  of  a  severe  dis- 
ease, in  hysteria  and  in  other  nervous  disorders.  In  disease 
urine  is  decreased  by  high  fever,  in  acute  inflannnajtion  of 
kidneys,  and  in  severe  infectious  diseases. 

Name  three  common  kinds  of  spirituous  liquors  and  de= 
scribe  their  manufacture. 

Spirituous  liquoi-s  are  divided  into  three  classes,  (a)  dis- 
tilled, including  whisky,  brandy,  etc. ;  (b)  fermented,  includ- 
ing wines;  and  (c)  malt  liquors,  including  the  beers. 

The  distilled  spirits  are  made  by  distilling  fermented 
liquors;  brandy  from  wine,  whisky  from  com  or  rye  or  other 
grain,  rum  from  molasses,  etc.  The  wines  are  made  by  fer- 
menting grape  and  other  fruit  juices.  The  beers  are  made 
by  fennenting  an  infusion  of  malted  barley  and  bops. 

Give  the  chemistry  of  photography. 

A  plate  is  prepared  with  an  emulsion  of  a  silver  salt  in 
gelatine,  and  on  exposure  to  light  this  silver  salt  undergoes 
reduction.  After  exposure  the  plate  is  treated  with  a  "  de- 
veloper "  by  which  the  reduced  silver  salt  is  still  further  re- 
duced, to  the  metal,  and  the  remaining  silver  salt  is  then  re- 
moved by  washing  in  a  solution  of  sodium  hyposulphite. 
From  this  negative  placed  upon  a  paper  prepared  in  much 
the  same  manner  as  the  plate  the  prints  are  obtained. 

Complete  the  following  equations  and  write  the  name 
of  each  resulting  compound  under  its  formula: 

Ca(OH),-f-C02=CaC03-fH20 

Calcium  carbonate  water. 
NaC2H30,-|-NaOH=:  CH4  +  Na2C03 

Marsh  gas  sodium  carbonate. 
What  is  meant  by  atomic  weight? 

The  atomic  weight  of  an  element  is  the  relative  weight  oi 
its  atom  as  compared  with  the  weight  of  an  atom  of  hydrogen. 


CHEMISTRY.  37 

Explain  the  difference  between  a  solid  and  a  liquid. 

In  a  solid  cohesion  binds  the  molecules  so  closely  together 
that  they  have  no  freedom  of  movement;  the  substance  pre- 
serves a  fixed  form. 

A  liquid  has  its  molecules  less  tightly  bound  together,  so 
that  they  may  flow  readily.  Cohesion  and  repellent  force 
are  about  equal.  A  liquid  has  no  fixed  form,  save  that  of  the 
containing  vessel. 

What  is  a  gas? 

The  molecules  making  up  a  gas  are  self-repellent,  each 
molecule  striving  to  pass  as  far  from  its  neighbors  as  possible. 
The  repellent  force  of  heat  has  overcome  the  force  of  cohesion. 

What  is  water  chemically  considered? 

Water  is  the  monoxide  of  hydrogen.  Its  composition  by 
weight,  one  part  of  hydrogen  and  eight  parts  of  oxygen.  By 
volume  two  parts  of  water  vapor  contain  two  parts  of  hydro- 
gen and  one  part  of  oxygen.  Water  may  act  as  an  electro- 
positive or  basic  body,  as  in  its  union  with  SO3.  to  form 
IT0SO4.  Or  it  may  act  as  an  electro-negative  or  acidulous 
body,  as  in  its  union  with  K^O,  to  form  2KH0. 

How  would  you  determine  the  specific  gravity  of  a 
liquid?  "" 

JJse  a  hydrx)meter :  An  instrument  of  glass,  cylindrical  in 
shape,  weighted  below,  and  terminating  above  in  an  upright 
stem,  upon  which  are  engraved  lines  indicating  degrees. 

Place  this  instrument  in  the  liquid  to  be  examined,  and 
note  to  which  mark  or  degree  the  instrument  sinks.  This 
degree  denotes  the  specific  gravity  of  the  liquid  compai'ed 
with  water. 

What  is  organic  chemistry? 

The  chemistry  of  tlie  liydrocarbons  and  their  derivatives. 

What  is  the  purpose  of  litmus  paper  in  urinalysis? 

For  determining  if  the  urine  be  acid,  alkaline  or  neutral 


38  CHEMISTRY. 

in  reaction,  also  whether  the  acidity  be  marked  or  slight,  and 
whether  the  alkalinity  be  of  fixed  or  volatile  character. 

How  is  excess  of  uric  acid  shown  in  the  urine? 

By  a  ring  of  w'hitish  color  forming  above  the  point  of  con- 
tact in  the  urine  when  urine  is  floated  on  nitric  acid  in  a 
test-tube ;  such  ring  disappears  when  gently  heated. 

What  effect  is  produced  in  mixing  air  with  a  blast  flame 
as  practiced  with  an  ordinary  bIow=pipe? 

The  air  so  dilutes  the  gas  as  to  bring  every  particle  of  the 
gas  in  contact  with  oxygen,  thus  occasioning  perfect  and 
complete  combustion.  The  air  also  directs  the  flame  to  a  de- 
sired point.  ' 

What  metallic  element  is  constantly  present  in  the  col- 
oring matter  of  the  blood? 

Iron. 

Explain  the  process  of  combustion. 

Combustion  is  chemical  union  taking  place  between  two  or 
more  substances,  accompanied  by  the  evolution  of  heat  and 
light. 

Name  the  lightest  of  all  known  elements. 

Hydrogen. 

Give  the  symbols  of  antimony,  silver,  gold,  iron  and 
zinc. 

Antimony,  Sb ;  silver,  Ag ;  gold,  Au ;  iron,  Fe ;  zinc,  Zn. 
How  would  you  prepare  hydrogen? 

Place  zinc  in  a  flask  provided  with  a  safety  funnel,  the 
lower  end  of  which  reaches  to  the  bottom  of  the  flask. 
Through  a  second  opening  in  the  stopper  of  the  flask  pass  an 
exit  tube,  the  lower  end  of  which  just  enters  the  flask.  Then 
pour  into  the  flask  through  the  funnel  dilute  sulphuric  acid. 
Hydrogen  gas  is  formed,  and  escapes  through  the  exit  tube. 

What  acid  contains  chlorine  as  an  important  element? 

Hydrochloric  acid,  HCl. 


CHEMISTRY.  39 

How  does  wine  differ  chemically  from  brandy? 

Wine  contains  from  6  per  cent,  to  25  per  cent,  of  alcohol; 
brandy  from  30  per  cent,  to  50  per  cent.  "Wine  is  a  product 
of  fermentation  of  fruit  juices;  brandy  results  from  distill- 
ing the  fermented  product  of  fruit  juices.  Wine  contains  a 
number  of  compound  volatile  ethers  that  are  not  present  in 
brandy. 

What  is  the  substance  (or  substances)  from  which  ordi= 
nary  alcohol  is  derived? 

Potato  starch  and  the  grains. 

What  element  constitutes  four=fifths  of  the  air? 

Nitrogen. 

Explain  the  principle  of  the  Bunsen  burner. 

The  Bunsen  burner  is  supplied  near  its  base  with  apertures 
for  the  ready  admission  of  air  and  its  mixture  with  the  gas. 
Each  particle  of  gas  is  thus  supplied  with  sufficient  oxygen  to 
obtain  perfect  combustion. 

What  is  the  essential  element  of  all  acids? 

Hydrogen, 

Name  three  elements  in  the  potassium  group. 

Potassium,  sodium,  lithium. 

Is  sulphurous  acid  a  solid,  a  liquid  or  a  gas  at  ordinary 
temperature? 

It  is  a  liquid  resulting  when  the  gas  SO2  is  dissolved  in 
water. 

What  is  albumin? 

It  is  a  complex,  colloidal,  proteid  body  composed  of  H,  C, 
O,  N,  and  S,  occurring  in  vegetable  and  animal  structures. 

Name  the  principal  sources  of  bromine. 

Natural  mineral  watere  containing  magnesium  bromide  in 
.s-olution,  and  sea  wa;t€r. 


40  CHEMISTRY. 

Give  the  name  and  formula  of  a  compound  of  sulphur 
and  hydrogen. 

Hydrogen  sulphide,  HgS. 

What  is  the  meaning  of  the  sesqui  in  chemical  nomen= 
clature? 

It  mieans  one  and  a  half,  and  refers  to  the  ratio  between 
combining  elements.     Example :  FeaOg,  sesqui-oxide  of  iron. 

Where  does  potassium  occur? 

In  rocks,  soil,  etc.,  in  form  of  silicates,  and  in  sea  waiter,  etc., 
in  form  of  chlorides  and  sulphates. 

Define  and  give  an  example  of  each  of  the  following: 
(a)  Binary  compound,  (b)  acid,  (c)  hydrate,  (d)  salt. 

(a)  A  compound  containing  two  elements,  as  AgCl.  (b) 
An  acid  is  a  salt  of  hydrogen ;  it  has  a  sour  taste,  turns  litmus 
red ;  has  corrosive  action,  when  concentrated,  upon  tissues ; 
unites  with  and  neutralizes  bases,  foraiing  salts  and  water. 
Example,  nitric  acid,  HNO3.  (c)  A  hydrate  is  a  compound 
of  a  metal  or  basic  radical  with  hydroxy  1,  OH.  Example, 
potassium  hydrate,  KOH.  (d)  A  salt  is  a  substance  formed 
,by  the  replacement  of  all  or  part  of  the  hydrogen  of  an  acid 
by  a  metal  or  basic  radical.  Example,  potassium  sulphate, 
K2SO,. 

V  What  are  the  laws  governing  combination  of  elements? 

1.  All  chemical  compounds  are  definite  in  their  composi- 
tion ;  the  ratio  of  the  elements  forming  them  is  constant. 

2.  If  one  element  unites  with  another  in  more  than  one 
proportion,  such  proportions  will  be  multiples  of  each  other. 

3.  The  proportion  by  weight  in  which  any  two  elements 
will  unite  with  a  third  element  represents  that  proportion  in 
which  they  would  unite  with  each  other  if  they  could  so 
combine. 

What  is  a  chemical  reagent? 

A  substance  having  an  active  chemicjal  effect  upon  otJier 


CHEMISTRY.  41 

cheini<3al  STi'bstances.     A  substance  which  by  its  contact  with 
another  substance  creates  new  compounds. 

Mention  a  pentad  element  and  explain  the  name. 

Nitrogen. 

A  pentad  element  is  one  the  atom  of  which  requires  five 
monad  a/to^ms  to  fully  satisfy  its  capacity  for  chemical  union. 

Explain  the  terms  (a)  amorphous,  (b)  alkali,  (c)  water 
of  crystallization,  (d)  nascent  state. 

(a)  Amorphous  means  without  form,  non-crystalline,  (b) 
Alkali,  a  body  possessing  the  strongest  of  basic  or  electro- 
positive properties,  usually  referring  to  oxides  and  hydroxides 
of  alkali  metals  or  metals  of  the  alkali  earths,  (c)  Water 
of  crystallization  is  water  necessary  to  the  crystal  form,  (d) 
Nascent  state,  or  newly  born,  refers  to  matter  in  its  atomic 
form,  or  before  the  individual  atoms  freed  from  a  compound 
have  united  to  form  molecules. 

What  are  the  properties  and  uses  of  glucose? 

A  white  or  yellowish-white,  sweetish  substance,  freely  sol- 
able  in  water,  possessing  not  quite  the  sweetening  power  of 
cane-sugar.  Grlucose  is  found  in  fruits,  in  honey,  and  in 
small  amount  in  the  various  fluids  of  the  body.  It  is  made 
from  cornstarch  by  treatment  \nth  dilute  acids.  It  has  food 
value  and  is  used  as  a  substitute  for  cane-sugar. 

What  is  the  difference  between  nitric  oxide  (NO)  and 
air? 

Nitric  oxide  is  a  compound  of  nitrogen  and  oxygen,  air  is 
tt  mixture  of  the  same  elements. 

Give  equation  for  the  production  of  ammonia  from  am- 
monium chloride  and  calcium  hydroxide. 

2Nir,Cl+("a(OlI)2=2NIl3+2TI.O+CaCL. 

How  was  salicylic  acid  originally  derived?  How  is  it 
now  manufactured?      What  are  its  properties? 

It  was  (n-iginally  obtaine<l  from  oil  of  gaulthena.  It  is  now 
Tri«.nufactnre<l  by  passing  COj  into  a  heated  retort  containing 


42  CHEMISTRY. 

sodium  Ga^pbonato,  C6H50Na+C02=C„H4(OH)CO.ONa,  and 
decomposing  this  sodium  salt  with  HCl. 

It  occurs  in  fine  white  needle-shaped  crystals,  permanent  in 
air,  of  sweetish  taste,  acid  reaction,  soluble  in  450  parts  of 
cold  water,  soluble  in  2  parts  alcohol;  solution  produces  in- 
tense violet  color  with  ferric  salts. 

Used  as  a  food  preservative,  as  an  antiseptic  and  antirheum- 
atic. 

Describe  the  method  of  preparing  H  by  the  action  of  Na 
on  H2O.  Write  the  formula  for  the  reaction  and  find  how 
many  grams  of  H  82  grams  of  Na  would  make  by  this 
process.     (The  atomic  weight  of  H  is  i,  of  O  16,  of  Na  23.) 

Place  a  piece  of  clean-scraped  sodium  in  a  combustion  spoon 
and  cover  it  with  a  cage  of  gauze  wire  to  hold  it  in  place.  Pill 
a  cylindrical  glass  jar  completely  full  of  water  and  invert 
mouth  down  in  the  pneumatic  trough. 

Plunge   combustion   spoon   containing   Na   quickly    under 
water,  below  the  mouth  of  the  glass  jar;  the  Na  at  once  de- 
composes water,  and  bubbles  of  hydrogen  gas  rise  in  the  jar. 
Na+H20=NaOH+H 
23-fl8=^0-fl 
23  grams  of  Na=:l  gram  H 
23 : 1 : :  82 :  X=3.565  of  H. 

Give  a  brief  description  of  three  experiments  illustrate 
ing  the  properties  of  oxygen. 

Plunge  a  smouldering  piece  of  charcoal  into  a  jar  of  oxygen 
and  the  charcoal  kindles,  burning  brilliantly. 

Heat  a  watch  spring  at  one  end  until  red-hot,  then  plunge 
into  jar  of  oxygen,  and  the  steel  spring  bums  with  great 
brilliancy. 

Place  a  piece  of  phosphorus  in  a  test-tube,  cover  it  with 
water,  warm  slightly,  and  then  by  means  of  a  long  glass  tube 
direct  a  jet  of  oxygen  upon  the  phosphorus;  the  latter  will 
cateh  fire,  burning  beneath  the  surface  of  the  water. 

What  is  the  source  of  phenacetin? 

It  is  an  anilid,  made  from  anilin,  a  product  of  coal-tar. 


CHEMISTRY.  43 

Give  the  occurrence  in  nature  of  phosphorus;  of  chlorine.. 

Phosphorus  occurs  in  nature  as  phosphate  of  calcium  in 
the  mineral  apatite,  and  as  phosphate  of  calcium  and  of  mag- 
nesium in  bones.  Chlorine  occurs  in  nature  chemically  com- 
bined with  metals,  as  NaCl,  AgCl,  etc.  As  NaCl  it  is  found 
in  sea  water,  river  water,  and  in  most  natural  waters,  in 
mineral  deposits,  as  rock  salt,  and  in  the  tissues  and  fluids  of 
animals  and  plants. 

What  are  the  chemical  names  of  (a)  borax,  (b)  marble, 
(c)  blue  vitriol? 

(a)  Sodium  tetra-borate,  or  sodium  pyro-borate.  (b)  Cal- 
cium carbonate,     (e)  Copper  sulphate. 

Define  positive  element,  negative  element.  Illustrate 
each. 

A  positive  element  is  one  which,  on  the  decomposition  of 
a  compound  by  electrolysis,  will  go  to  the  negative  electrode. 

A  negative  element  is  one  which,  on  the  decomposition  of 
a  compound  by  electrolysis,  will  go  to  the  positive  electrode. 

Iron,  gold  and  hydrogen  are  positive  elements.  Oxygen, 
sulphur  and  chlorine  are  negative  elements. 

Mention  the  halogens  and  state  in  what  respects  they 
exhibit  marked  similarity. 

Chlorine,  bromine,  iodine,  fluorine. 

All  are  monads,  all  electro-negative,  all  form  hydrogen 
acids,  all  possess  bleaching  or  disinfectant  action,  all  combine 
with  metals.  Except  fluorine,  all  form  oxy-acids  and  oxy- 
saks. 

Mention  the  properties  of  hydrogen. 

Hydrogen,  symbol  H,  atomic  weight  1,  valence  I,  is  a  color- 
less, odorless,  tasteless  gas.  The  lightest  of  the  well-known 
elements.  Practically  insoluble  in  water,  burns  with  a  color- 
less flame,  yielding  more  heat  in  its  burning  than  any  equal 
weight  of  any  other  substance.  In  its  combustion  in  air  it 
forms  water.  Mixtures  of  hydrogen  with  oxygen  or  air  ex- 
plode when  ignited. 


44  CHEMISTRY. 

Hydrogen  is  not  poisonous,  but  will  not  support  life,  nor 
will  it  support  combustion.  It  is  electro-positive.  When 
liquefied  it  forms  a  steel-blue  liquid  that  is  opaque  to  the 
passage  of  light.  It  is  used  as  a  standard  for  many  scientific 
determinations. 

State  (a)  the  normal  specific  gravity  of  urine,  (b)  the 
causes  of  abnormal  deviations  in  the  specific  gravity  of 
urine. 

(a)  From  1018  to  1025.  (b)  Specific  gravity  is  lowered  in 
polyuria,  as  of  diabetes  insipidus  in  chronic  interstitial  neph- 
ritis.   In  certain  nervous  disorders,  as  hysteria,  chorea,  etc. 

Specific  gravity  is  above  1025  in  diabetes  mellitus,  in  acute 
inflammation  of  kidney,  in  certain  crises  in  the  course  of 
chronic  nephritis  accompanied  by  partial  suppression  of  urine. 
In  certain  disorders  of  digestion.     In  febrile  affections. 

Mention  the  principal   chemical   constituents  of   bile. 

Water,  mucus  and  pigment,  glycocholate  of  sodium,  tau- 
rocholate  of  sodium,  soaps,  fat,  lecithin,  cholesterin. 

State  the  properties  of  aluminum  and  mention  its  im- 
portant salts. 

A  silvery- white  metal,  sp.  gr.  2.67,  hard,  ductile,  malleable, 
only  superficially  acted  upon  on  exposure  to  air,  soluble  in 
hydrochloric  acids  and  in  alkalies.  The  official  compounds 
are  the  hydroxide,  sulphate  and  the  double  sulphate  of  potas- 
sium and  aluminum. 

Give  the  properties  of  two  important  compounds  of  zinc 
used  medicinally. 

Zinc  sulphate,  ZnSO^,  a  white  granular  crystalline  powder, 
used  as  an  astringent,  soluble  in  water  and  used  in  waitery 
solution  for  local  application.  Internally,  is  used  as  an 
emetic,  a.nd  in  diarrhoea,  etc.  Zinc  oxide,  a  yellowish-white 
powder,  insoluble  in  water,  odorless  and  tasteless,  used  in 
dyspepsia,  night  sweats,  epilepsy,  chorea,  and.  externally,  in 
ointment  form. 


CHEMISTRY.  45 

Give  in  detail  two  tests  for  ascertaining  the  presence  of 
albumin  in  the  urine. 

A  long  test-tube  is  three-quarters  filled  with  filtered  urine, 
and  the  upper  portion  is  heated  to  boiling.  If  a  cloud  or 
precipitate  appeal's,  add  a  few  drops  of  nitric  acid — phos- 
phates will  dissolve  and  any  cloudiness  remaining  will  be 
due  to  albumin. 

Place  a  10  per  cent,  solution  of  ferrocyanide  of  potassium 
in  a  test-tube  and  add  to  it  half  its  volume  of  acetic  acid; 
mix  well.  Then  run  down  the  side  of  the  tube  the  suspected 
urine  so  that  it  floats  upon  the  reagent  without  mixing.  If 
albumen  is  present  there  will  be  impairment  in  transparency 
of  the  liquids,  or  even  an  evident  precipitation  if  much  albu- 
min be  present. 

What  are  compound  ethers?    Give  an  example. 

Compound  ethers  are  salts  of  hydrocarbon  radicals,  e.  g., 
aniyl  nitrite,  C5H11NO2. 

What  is  glycerine? 

Glycerine,  03115(011)3,  a  triatomie  alcohol  obtained  by  de- 
composition of  the  fats,  is  a  bland,  heavy  liquid  of  a  charac- 
teristic sweetish  taste,  with  a  marked  attraction  for  water 
and  great  solvent  powers,  particularly  for  oils,  and  for  many 
<lrug  substanees. 

State  the  preparation,  appearance,  formula  and  uses  of 
acetic  acid. 

Acetic  acid,  HC2H3O2,  may  be  obtained  by  destructive  dis- 
tillation of  wood,  being  separated  and  purified  from  the  im- 
pure product,  pyroligneous  acid. 

It  is  a  colorless  liquid  of  strong,  characteristic  pungent, 
<xlor  and  a  sour  or  corrosive  tast«  and  action.  In  concen- 
trates! form  it  crj'stallizes  at  about  60  degrees  F.  It  is  used 
for  softening  and  removing  callous  tissues,  as  a  disinfectant, 
and  in  preparation  of  its  salts. 


46  CBEMISTRT. 

What  chemical  changes  take  place  in  the  body  after 
death? 

The  fats  undergo  gradual  decomposition ;  oxidation  of  var- 
ious tissues  takes  place,  sulphuretted  hydrogen  is  produced. 
Phosphorus  leaves  its  chemical  combinations  in  bone  and 
other  tissues  to  combine  with  hydrogen,  forming  PH3.  Nitro- 
gen unites  with  hydrogen  to  form  NH3.  In  general  the  com- 
plex body  substances,  proteids,  etc.,  split  up  into  simpler 
compounds. 

Define  base,  basic  radical,  isomerism. 

A  base  is  the  oxide  or  hydroxide  of  a  metal  or  basic  radical. 
It  is  a  substance  which  in  solution  will  neutralize  an  acid 
to  form  salt  and  water. 

A  basic  radical  is  an  atom,  or  an  unsaturated  group  of 
atoms,  having  an  electro-positive  condition  and  an  action 
similar  to  that  of  a  base. 

Isomerism  is  that  property,  due  to  the  atomic  arrangement, 
by  virtue  of  which  chemical  compounds  may  be  composed 
of  the  same  elements  in  the  same  percentage  proportion  by 
weight  yet  be  different  and  distinct  substances  having  dif- 
ferent properties. 

State  the  normal  reaction  of  urine.  How  is  the  reaction 
noted?    To  what  is  it  due? 

Reaction  acid.  By  use  of  litmus  paper,  which  should  turn 
red  when  moistened  with  urine.  Acidity  due  chiefly  to  pres- 
ence of  acid  phosphate  of  sodium. 

Define  qualitative  analysis,  quantitative  analysis.  IIlus= 
trate  each. 

Qualitative  analysis  seeks  to  know  ivhat  substances  are  pres- 
ent in  a  compound  or  mixture.  Quantitative  analysis  seeks 
to  know  how  much  of  a  substance  is  present.  We  test  quali- 
tatively to  see  if  there  is  any  albumin  in  a  sample  of  urine; 
we  test  quantitatively  to  find  out  how  much  albumin  is  present. 

Describe    the   chemical   process   for   the    preparation   of 


CHEMISTRY.  47 

alcohol.    What  percentage  of  alcohol  is  found  in  (a)  beer, 
(b)  wine,  (c)  whiskey,  (d)  brandy? 

Starch  is  converted  into  dextrose,  and  this  is  then  changed 
by  the  action  of  yeast  into  alcohol  and  carbon  dioxide. 
2CeH,oO,+H30=CeH,30e+  CeH^.O^ 
Starch  Dextrose         Dextrin 

CeHj^Oe  +  yeast  =  2C2H,OH  +  2CO2. 
(a)   About  5  per  cent.,   (b)   6-25  per  cent.,   (c)   30-60  per 
cent.,  (d)  30-50  per  cent. 

Describe  two  tests  for  glucose. 

Glucose  in  solution,  if  boiled  with  an  alkaline  cuprie  hy- 
drate solution,  reduces  the  copper  salt  to  the  red  sub-oxide 
of  copper,  forming  a  precipitate. 

Glucose  in  solution  placed  in  the  polarizing  saccharimeter 
bends  the  rays  of  light  towards  the  right. 

What  are  peptones  and  how  are  they  produced? 

Peptones  are  dialyzable,  feebly  acid,  proteid  products 
formed  by  the  action  of  the  digestive  ferments  upon  albu- 
minous bodies.  They  are  very  soluble  in  water,  and  are  in- 
soluble in  alcohol  and  ether. 

How  do  globulins  differ  from  albumins? 

Globulins  are  insoluble  in  water,  albumins  are  soluble. 
Globulins  are  precipitated  by  saturated  solutions  of  NaCl, 
albumins  are  not. 

Complete  the  equation:   NaC2H30,+NaOH=. 

NaC  JI3O2  +  NaOII  =-  CH,  -f  Na^COg. 

Explain  the  nomenclature  of  binary  compounds.  Which 
element  is  to  be  placed  first,  and  how  is  the  termination 
of  the  second  to  be  altered? 

Binary  compounds  are  those  composed  of  two  elements. 
The  electro-positive  or  metallic  element  is  named  first,  the 
name  of  the  second  element  terminating  in  "  ide. "  Exam- 
7)les:  Ag.^S,  silver  sulphide;  NaCl,  sodium  chloride. 

Binary  acids,  HCl,  PIBr,  etc..  have  the  prefix,  "  hydro," 
and  the  suffix.  "  ic." 


48  CHEMISTRY. 

Define  anhydride,  latent  heat,  gravitation. 

An  lanhydrdde  is  a  substanice  minus  water;  the  name  is 
applied  most  frequently  to  acidulous  oxides  that  are  capable 
of  combining  chemically  with  water  to  form  acids,  as  SO^, 
sulphuric  anhydride ;  NgOg,  nitric  anhydride. 

Laitent  heat  is  heat  not  manifesting  itself  as  temperature; 
it  is  the  heat  energy  used  up  in  overcoming  molecular  attrac- 
tion. 

Gravitation  is  the  force  of  attraction  between  m'asses  of 
matter. 

Describe  methods  for  determining  atomic  weights. 

1.  Determine  the  specific  gravity  of  the  element  when  in 
the  gaseous  state  compared  with  hydrogen. 

2.  The  product  of  the  atomic  weight  multiplied  by  the 
specific  heat  being  6.4,  divide  6.4  by  the  ascertained  specific 
heat  of  the  element. 

3.  Note  the  weight  of  an  element  required  to  take  the  place 
of  a  given  weight  of  hydrogen  in  forming  a  replacement  or 
substitution  compound.  Thus  acetic  acid  is  HC2H3O2,  and 
practical  experiment  shows  that  one  grain  of  hydrogen  in 
acetic  acid  may  be  replaced  by  108  grains  of  silver  to  form 
silver  acetate,  AgCoHsOg ;  hence  one  equivalent  of  silver 
weighs  108  times  that  of  hydrogen,  or  one  atom  of  silver 
weighs  108  compared  to  the  weight  of  one  atom  of  hydrogen. 

Explain  the  difference  between  metals  and  non=metals. 

Metals  are  electro-positive  and  combine  with  oxygen  to 
form  basic  oxides.  Non-metals  are  electro-negative  and  com- 
bine with  oxygen  to  form  acid  oxides. 

Explain  the  process  of  manufacturing  sulphuric  acid  on 
a  large  scale. 

Sulphur  or  a  sulphide  is  burned  in  a  plentiful  supply  of 
air,  and  the  resulting  sulphur  dioxide  gas,  SO2,  is  carried 
into  a  series  of  leaden-lined  chambers  along  with  vapor  of 
nitric  acid  and  steam.  The  sulphur  dioxide  becomes  oxidized 
to  sulphur  tri oxide  (SO3)  through  the  action  of  the  nitric 
acid  vapor,  and  combines  chemically  with  the  water  (steam) 
to  form  sulphuric  acid,  H2SO4. 


CHEMISTRY.  49^ 

State  the  symbol,  valence  and  atomic  weight  of  phos- 
phorus. 

Symbol,  P;  valency,  III.  and  V.  Atomic  weight,  31.0 
(30.77).  4 

What  is  glycogen?    From  what  is  it  derived? 

Glycogen  (CaHioOg)^,  a  carbohydrate  of  the  amylose  series, 
resembles  starch,  forms  opalescent  solution  in  cold  water, 
derived  chiefly  from  the  carbohydrates  of  the  food,  being 
formed  in  the  liver  and  other  body  cells. 

Give  and  explain  (a)  an  empiric  formula,  (b)  a  rational 
formula. 

(a)  The  simplest  possible  expression  by  formula  of  the  com- 
position of  a  compound,  giving  the  kind  of  elements  present 
and  the  proportionate  number  of  atoms,  thus,  CH2O  is  an 
empiric  formula  for  acetic  acid. 

(b)  A  rational  formula  shows  the  manner  in  which  the 
different  atoms  or  radicals  combine  in  order  to  make  one 
molecule  of  the  body,  thus  CH3CO.OH  is  a  rational  formula 
for  acetic  acid. 

What  is  the  chemical  antidote  for  poisoning  from  lead 
acetate?     Explain  the  chemical  action  of  this  antidote. 

A  soluble  sulphate,  as  magnesium  sulphate  (Epsom  salts), 
which  in  contact  with  acetate  of  lead  forms  the  insoluble  sul- 
phate of  lead. 

Pb ( C2H3O,)  2  +  MgSO,  =  PbSO,  -f  Mg( CAO^) ,. 

Complete  the  following  equations  and  give  the  names 
of  the  resulting  compounds: 

HgSO,  4-  Hg  +  2NaCI  = 
FeSO, +  2NaHC03  = 

HgSO^  +  Hg  +  2NaCl  =  Hg^Cl^  (or  2HgCl)  -\-  Na^SO, 

('nlomol  Sodium  siilpliate 

FeSO,  +  2NaIIC0a  =  FeCOa  +  H^O  +  Na^SO^  -f  CO^ 

Ferrous  water         Sodium  ciirbun 

carbonate  sulphate         dioxidw 


50  CHEMISTRY. 

Define  chemical  action,  physical  action.  Give  examples 
of  each. 

Chemieal  action  takes  place  in  the  interior  of  the  molecule. 
It  is  accompanied  by  the  development  of  heat.  When  chemi- 
cal action  occurs  the  identity  of  the  bodies  entering;  into  the 
reaction  is  lost,  and  new  substances  are  produced.  Chemical 
action  takes  place  between  defiuite  weights  of  the  substances. 

Physical  action  takes  place  outside  of  the  molecule.  It  is 
not  necessarily  accompanied  by  the  evolution  of  heat.  The 
substances  do  not  lose  their  identity.  Any  quantities  of  the 
substances  may  undergo  physical  action.  Examples:  Chem- 
ical action,  add  HCl  to  marble  dust,  forming  a  gas,  carbon 
dioxide,  water  and  chloride  of  calcium.  Physical  action,  add- 
ing water  to  sugar  we  eflfect  thereby  a  solution,  without  chem- 
ical change. 

State  the  chemical  changes  produced  within  a  galvanic 
cell  while  in  action. 

Cell  composed  of  zinc  and  copper  with  dilute  sulphuric 
acid.  The  acid  dissolves  zinc,  forming  a  solution  of  zinc  sul- 
phate. The  hydrogen  of  the  acid  is  given  off  in  bubbles, 
from  the  copper.  Thus  the  strength  of  acid  is  constantly 
lessened  through  its  decomposition  and  the  formation  of  sul- 
phate of  zinc,  until  finally  all  acidity  will  have  disappeared 
from  the  battery  fluid. 

Define  distillation,  sublimation,  destructive  distillation. 
Give  examples  of  each  process. 

Distillation  consists  in  the  passing  of  a  liquid  into  a  vapor- 
ous condition  when  heaited  to  its  boiling  point,  and  the  sub- 
sequent condensation  of  this  vapor  again  to  the  liquid  form 
on  cooling  the  vapor.     Example:  Distillation  of  water. 

Sublimation  is  the  passage  of  a  solid  into  a  vapor  on  being 
heated,  and  the  condensation  of  this  vapor  again  to  the  solid 
form  on  cooling,  without  the  substance  having  undergone 
decomposition.  Example :  The  sublimation  of  iodine.  De- 
structive distillation  is  a  form  of  distillation  in  which  the 
original   substance  in  the   retort  is  destroyed,   and   from  the 


CHEMISTRY.  51 

vapors  arisring  new  substances  are  collected.  Example :  By 
the  destructive  distillation  of  wood  we  obtain  creosote,  pyro- 
ligneous  acid.  etc. 

What  are  the  constituents  of  common  illuminating  gas? 
How  is  it  prepared?     Why  is  it  poisonous? 

j\lai-sh  gas,  CH^,  olefiant  gas,  CoH^,  acetylene  gas,  CjHg, 
carbon  monoxide,  carbon  dioxide,  hydrogen,  and  traces  of 
nitrogen,  and  sulphur  compounds.  It  is  prepared  by  the 
destructive  distillation  of  bituminous  coal.  Its  poisonous 
effects  are  largely  due  to  carbon  monoxide  present. 

Illuminating  gas  is  also  made  by  the  water  gas  process, 
pas^sing  air  and  steam  over  highly  heated  carbon,  and  subse- 
quently enriching  by  mixing  with  naphtha  vapors. 

Describe  the  preparation  and  appearance  of  flowers  of 
sulphur,  roll  sulphur,  precipitated  sulphur. 

Flowers  of  sulphur,  prepared  by  subliming  sulphur  and 
cooling  the  vapor.  It  is  yellow  in  color,  and  examined  by  the 
mdcroscope  shows  rounded  globular  masses. 

Roll  sulphur,  of  yellow  color,  in  sticks  about  two  feet  in 
length  and  two  inches  in  diameter.  Obtained  by  pouring 
molten  sulphur  into  Avooden  moulds. 

Precipitated  sulphur,  a  white  or  greenish-white  powder, 
is  prepared  by  boiling  together  sulphur  and  lime  and  then 
decomposing  the  compound  produced  by  the  addition  of 
hydrochloric  acid. 

Mention  the  substances  used  for  disinfection  after  the 
prevalence  of  contagious  disease  and  explain  their  action. 

Sulphur  burned,  forming  S0„,  which  acts  as  a  disinfectan^^ 
through  its  dehydrating  effect  upon  germ  life. 

C'lilorinated  lime  in  presence  of  acid  and  by  action  of  the 
utmospheric  carbon  dioxide  liberates  chlorine  gas,  and  this 
latter,  comhining  chemically  with  hydrogen  of  moisture,  sets 
oxygon  free;  the  oxygen  then  acts  destructively  upon  disease 
germs. 


52  CHEMISTRY. 

Formaldehyde,  in  solution  or  as  gas,  acts  a^  a  direct  germi- 
cide, as  do  also  phenol,  mercuric  chloride,  etc. 

What  percentage  of  COg  exists  normally  in  the  atmos- 
phere?   What  percentage  COo  is  dangerous  to  life? 

Atmospheric  air  contains  .04  per  cent,  by  volume  of  COg. 
A  greater  percentage  of  COg  than  3.0  per  cent,  by  volume 
would  be  dangerous  to  life  if  the  COg  were  accompanied  by 
impurities  from  animal  respiration.  Ten  per  cent,  of  COj 
in  air  will  prove  poisonous,  although  unaccompanied  by  re- 
spiratory impurities. 

State  the  properties  of  nitric  acid. 

Nitric  acid,  HNO3,  specific  gravity  of  strong  acid,  1.4, 
colorless  liquid,  fuming  in  air,  highly  corrosive,  stains  upon 
tissues  or  fabrics  not  discharged  by  the  use  of  ammonium 
hydroxide.  It  turns  litmus  red,  will  dissolve  most  of  the 
metals,  parts  readily  with  its  oxygen,  forming  nitrous  acid. 

Define  and  describe  sugars.  How  do  glucoses  differ 
from  saccharoses?  What  kind  of  sugar  is  found  in  dia= 
betic  urine? 

Sugars  are  organic  compounds  called  car'bohydrates ;  all 
consist  of  C,  H,  and  0,  with  six,  or  a  multiple  of  six,  atoms 
of  carbon  and  twice  as  many  H  atoms  as  0  atoms.  They 
occur  in  vegetable  and  animal  structures.  Glucoses  are  repre- 
sented by  the  formula  CgHiaOe;  they  reduce  cupric  hydrate 
to  the  red  cuprous  oxide.  They  crystallize  with  difficulty; 
they  are  less  sweet  than  cane-sugar. 

Saccharoses,  formula  C12H22O11,  include  the  true  sugars, 
cane-sugar,  lactose,  maltose.  They  may  be  regarded  as  anhy- 
drides of  the  glucoses.  They  readily  crystallize,  and  possess 
maximum  sweet  taste. 

Glucose  is  found  in  diabetic  urine. 

Give  the  chemical  name  and  properties  of  (a)  calomel, 
(b)  corrosive  sublimate.  Mention  two  easily  applied  tests 
that  will  distinguish  one  from  the  other. 

(a)    Calomel,  mercurous  chloride  HgaCL  or  HgCl.     Is   3. 


CHEMISTRY.  53 

laxative,  may  by  continued  use  cause  constitutional  poisoning ; 
occurs  as  an  impalpable,  insoluble  powder.  When  added  to 
lime  water  a  black  mixture  results. 

(b)  Corrosive  sublimate,  mercuric  chloride,  HgClg  is  an 
alterative,  anti-syphilitic,  antiseptic  and  highly  poisonous 
substance.  It  occurs  in  heavy  white  crystals,  soluble  in  13 
parts  of  water,  and  in  3  parts  of  alcohol.  When  added  to 
lime  water  a  yellow  mixture  results. 

Give  the  chemical  name  of  iodoform.  How  is  iodoform 
made? 

Iodoform  is  tri-iodomethane,  CHI3.  It  is  made  by  the 
action  of  iodine  and  potassium  hydroxide  on  ethyl  alcohol. 

State  the  atomic  theory. 

All  matter  is  composed  of  minute  particles  called  molecules, 
and  each  molecule  is  made  up  of  indivisible  parts  called 
atoms ;  these  latter  in  their  union  to  f onn  molecules  unite 
in  fixed  quantities  by  weight  and  in  obedience  to  fixed  laws. 

Give  the  properties  and  uses  of  bromine. 

Bromine,  Br,  atomic  weight  80.0  (79.36),  valence  I,  is  a 
heavy  red-brown  volatile  liquid,  specific  gravity  2.99.  It 
vaporizes  at  all  temperatures,  giving  rise  to  reddish-brown 
fumes.  It  is  slightly  soluble  in  water,  soluble  in  alcohol  and 
dn  ether,  is  caustic,  and  its  vapor  is  irrespirable.  It  combines 
with  many  metals  to  form  binary  salts,  called  bi-omides,  e.  g. 
NaBr,  KBr,  AgBr.  Used  as  a  disinfectant,  for  cleansing  foul 
wounds,  and,  in  its  salts,  internally  as  medicine. 

State  the  valence  of  the  following  radicals:  (CN),  (HO), 
(NO2),  (CO),  (HC). 

CN.  monad ;  HO.  monad ;  NO.,  monad ;  CO,  dyad ;  HC, 
triad. 

Give  the  names  and  formulas  of  three  sodium  salts. 

Sodium  bromide  NaBr.  Sodium  chloride  NaCl.  Sodium 
jodide  Nal. 


54  CHEMISTRY. 

How  is  ferric  chloride  made?  Give  the  chemical  equa= 
tions. 

Dissolve  iron  in  aqua  regia,  or  ferric  oxide  in  hydrochloric 
acid. 

Fe^  -h  6HC1  +  2HNO3  =  Fe^Clg  +  N^O^  +  ^H^O. 
Fe^O,,  4-  6HC1  =  Fe.Cle  +  3H,0. 

Give  in  detail  a  test  for  arsenic  in  a  mixture  of  food 
taken  from  the  stomach. 

To  the  stomach  contents  add  an  equal  weight  of  a  mixture 
of  HCl  (1  part)  and  water  (3  parts).  Digest  on  a  water- 
bath  and  add  small  quantities  of  potassium  chlorate  until  the 
organic  mater  is  destroyed.  Then  filter,  drive  off  the  chlor- 
ine by  passing  COo  gas,  and  reduce  the  arsenic  compound  to 
the  arsenous  by  passing  SO,  gas. 

Heat  to  drive  off  any  excess  of  sulphurous  acid,  then 
through  the  resulting  liquid  pass  hydrogen  sulphide  gas  for 
several  hours.  Collect  this  precipitate,  and  to  it  add  am- 
monium hydrate.  Test  the  dissolved  portion  or  filtrate  for 
arsenic  by  Marsh's  test. 

Define  allotropism. 

Allotropism  refers  to  elements  occurring  in  more  than  one 
form,  as,  for  instance,  carbon  in  charcoal,  graphite  and  dia- 
mond. 

Give  the  average  amount  and  the  composition  of  normal 
urine  voided  by  an  adult  in  24  hours. 

Amount  50  ounces 

Solids 1000  grains 

Urea 500     "  chlorides  (KNa) 170  grains 

Uric  acid 10     "  sulphates  (KCa) 40      '' 

Hippuric  acid- ..       15     "  phosphates  (KNa) 45      "■ 

Creatinine 15     "  ■'  (MgCa) 30      '' 

Pigment,  mucus,  xanthine,  other  extractives. 

Mention  five  alkaloids.    Give  the  derivation  of  each. 

Strychnine  from  nux  vomica;  morphine  from  opium;  qui- 
nine from  cinchona  bark;  cocaine  from  erythroxylon  coca; 
atropine  from  belladonna. 


CHEMISTRY.  55 

Complete  the  following  equations: 
CH3l  +  HKS= 
CS2+2H20+6Cu= 

CH3I  +  HKS  =  CH3HS  +  KI. 

CS,  +  2IL0  +  6Cu  =  2H,S  +  CO.  +  6Cu. 

State  the  properties  of  potassium.  Mention  ten  potas- 
sium compounds  of  importance  in  medicine.  Give  for= 
mulae. 

Potassium,  K,  at.  wt.  39.U  (38.86),  valence  I,  is  a  soft 
white  metal,  slight  bluish  tint,  decomposes  water  at  all  tem- 
peratures. It  is  one  of  the  strongest  electro-positive  elements, 
is  of  monad  valency,  is  lighter  than  water,  fuses  below  a  red 
heat. 

Compounds  of  importance  in  medicine  are:  PotaSvsium 
iodide,  KI;  nitrate,  KNO3;  carbonate,  KgCOg ;  bromide,  KBv, 
chlorate,  KCIO3 ;  chloride,  KCl ;  sulphate,  K2SO4 ;  bl-carbon- 
ate,  KHCO3 ;  c.vanide,  KCN ;  and  antimonial  tartrate,  KSbO- 
CJI,0«. 

Give  a  method  of  determining  the  specific  gravity  of  a 
solid  substance  insoluble  in  water. 

Weigh  substance  in  air,  then  innnerse  in  water  and  weigh 
again;  divide  weight  in  air  by  loss  in  weight  in  water.  Ex- 
ample :  Gold  weighs  10  grains  in  air,  in  water  weighs  9^/^ 
grains,  loss  equals  half  a  grain,  then  10,  weight  in  air,  di\'ided 
by  one-half,  or  the  loss  of  weight  when  in  water,  equals  20, 
the  specific  gravity  (approximate)  of  gold. 

Give  the  chemical  name,  properties  and  uses  of  tartar 
emetic. 

Tartar  emetic  is  potassium  antimonyl  tartrate.  Fonnula  : 
KSbOCJI^O,,. 

It  oecui's  in  crystals  or  as  a  white  solubU^  l)()wder,  chare 
■when  heated.  Used  as  an  emetic  aiul  as  a  sedative  expec- 
torant, is  very  poisonous. 

In  what  part  of  the  body  Is  sulphur  found? 

Sulphur  exist«  in    pi-actically  all   tissues  and    Huids  of  the 


b6  CHEMISTRY. 

*body  in  the  form  of  sulphates  and.  in  combination,  in  the 
tsiibstances  of  albuminoid  nature. 

What  kind  of  albumin  in  morbus  Brightii?  What  prop- 
erty renders  it  readily  detectable? 

Serum  albumen. 

It  is  readily  detected  through  its  coagulability  by  heat  and 
by  acid. 

How  is  chlorinated  lime  made?  What  is  the  principal 
use  of  chlorinated  lime? 

By  passing  chlorine  gas  over  slaked  lime. 

Ca(0H)2  +  CI2  =  OaClOCl  +  H^O. 

Its  chief  uses  are  as  a  bleaching  agent  and  a  disinfectant. 
Chlorinated  lime  liberates  chlorine  when  in  contact  with  an 
acid  or  with  the  atmospheric  carbon  dioxide. 

What  is  the  difference  between  an  alcohol  and  a  phenol? 
Illustrate. 

Phenols  differ  from  alcohols  in: 

1st.  Not  forming  aldehydes  and  acids  on  oxidation. 

2d.  In  not  dividing  into  water  and  hydrocarbons  under 
the  influence  of  dehydrating  agents. 

3d.  In  not  reaoting  with  acids  to  form  ethers. 

Phenols  form  more  stable  compounds  than  do  alcohols  with 
the  metallic  elements. 

What  are  carbohydrates?  Into  what  three  groups  are 
these  compounds  usually  divided? 

Carbohydrates  are  organic  compounds,  composed  of  C,  H, 
0,  in  which  the  H  and  0  exist  in  the  relative  proportions  in 
which  they  are  present  in  water  and  the  carbon  atoms  in 
groups  of  six. 

Polysaccharids  or  amyloses,  monosaceharids  or  glucoses, 
disaccharids  or  sucroses. 

Give  the  formula,  uses  and  properties  of  hydrogen 
dioxide. 

H2O2.  Used  as  a  disinfectant,  bleaching  and  oxidizing 
agent. 


CEEMISTBY 


0/ 


It  is  usually  sold  in  a  watery  solution  containing  from  10 
t^  12  volumes  of  true  hydrogen  dioxide  or  about  3  per  cent, 
■by  weight.  True  hydrogen  dioxide  is  a  thick,  syrup-like 
liquid  obtained  through  the  evaporation  of  its  watery  solu- 
tions over  strong  sulphuric  acid  in  a  vacuum.  It  readily 
parts  with  an  atom  of  oxygen,  particularly  if  brought  in 
contact  with  organic  matter,  and  it  is  this  nascent  oxygen 
that  effects  the  bleaching,  disinfectant  action,  etc. 

Give  the  formula  and  properties  of  each  of  two  oxides 
of  carbon,  explaining  the  effect  of  each  on  animal  life. 

Carbon  monoxide,  CO.  A  gas  almost  insoluble  in  water, 
no  odor,  burns  with  blue  flame  to  form  carbon  dioxifle,  is 
lighter  than  air.  It  acts  as  a  direct  poisonous  agent  to  ani- 
mals, uniting  with  the  hemoglobin  of  the  blood,  and  thus 
destroying  the  oxygen-carrying  power  of  the  red  corpuscles. 

Carbon-dioxide,  CO,,  is  a  colorless  gas,  heavier  than  air, 
no  odor,  soluble  in  water,  a  normal  constituent  of  air.  It  is 
not  a  direct  poison  when  inhaled,  unless  in  quantities  con- 
stituting over  10  per  cent,  of  the  inhaled  air.  It  is,  how- 
ever, not  capable  of  supporting  life.  It  does  not  burn,  nor 
does  it  support  combustion. 

Describe  the  preparation  of  nitrous  oxide,  writing  the 
reaction.    State  the  properties  and  use  of  nitrous  oxide. 

Nitrous  oxide  results  when  ammonium  nitrate  is  heated  in 
a  retort  at  temperatures  between  460°  to  490°  F. 
NII.NOg  +  heat  =  N20  +  2H2O. 

It  is  a  colorless  gas,  slightly  sweetish  taste,  has  no  odor. 
It  is  soluble  in  water,  heavier  than  air.  It  readily  supports 
combustion,  owing  to  its  decomposition  by  the  heat  of  the 
burning  body.  It  does  not  burn.  It  is  used  for  the  produc- 
tion of  general  anesthesia  of  a  short  duration. 

Describe  phosphorus  as  to  (a)  derivation,  (b)  proper- 
ties, (c)  commercial  uses,  (d)  medicinal  uses,  (e)  medic- 
inal  preparations. 

(a)  From  the  mineral  apatite  or  from  bones,  the  latter 
containing  tri-caloium  phosphate. 


58  CHEMISTRY. 

(b)  In  its  usual  form  is  a  yellow  wax-like  solid,  oocurring 
also  in  red,  black  and  white  allotropic  forms. 

Yellow  phosphorus  is  spontaneously  inflammable  in  air, 
especially  if  it  be  finally  divided,  has  an  odor  of  garlic,  is 
highly  poisonous,  is  insoluble  in  water,  but  dissolves  in  oils, 
in  carbon  disulphide,  slightly  soluble  in  hot  alcohol,  etc.  It 
glows  in  the  dark,  it  melts  and  will  take  fire  below  the  boil- 
ing-point of  water. 

(c)  Making  matches,  insecticides.  Is  Used  in  certain  metal 
alloys  to  give  closer  grain  and  prevent  oxidation  in  the  alloy, 
as  in  phosphor  bronze. 

(d)  Used  medicinall}^  in  doses  of  1-lOOth  of  a  grain  in 
nerve  disorders. 

(e)  'Medicinal  preparations — phosphorus,  phosphoric  acid 
dilute,  the  phosphates,  hypophosphites  and  phosphides. 

Give  the  names  and  formulas  of  the  various  gaseous 
compounds  capable  of  producing  general  anesthesia. 

Nitrous  oxide,  NoO ;  chloroform,  CHCI3;  ether,    (€2115)20. 

A  few  other  substances  are  used  for  the  production  of 
anesthesia,  but  they  have  not  as  general  a  use  nor  are  they 
generally  as  satisfactory. 

Describe  a  method  of  detecting  the  presence  of  lead 
salts  in  water. 

Concen'trate  the  water  to  small  bulk,  add  a  few  drops  of 
ammonium  sulphide — a  black  or  brownish-black  precipitate 
or  coloration  insoluble  in  dilute  hydrochloric  acid  indicates 
the  presence  of  lead. 

How  may  the  presence  and  amount  of  urea  be  deter= 
mined? 

Make  a  fresh  solution  of  hydrobromate  of  sodium  by  dis- 
solving 100  grams  of  caustic  soda  in  250  cubic  centimeters 
of  water,  and  when  cold  adding  25  grams  of  bromine. 

Place  this  solution  in  the  closed  arm  of  a  Doremus'  ureo- 
meter.  Now  add  one  cubic  centimeter  of  urine,  so  that  it 
may  mix  with  the  hypobromite  solution  in  the  long  arm  of 


CHEMISTRY.  59 

the  apparatus.  The  urea  is  decomposed,  its  eouipouents  are 
absorbed  with  the  exception  of  nitrogen  gas,  which,  passing  to 
the  upper  portion  of  the  tube,  depresses  the  column  of  liquid 
do^vnward.  The  space  occupied  by  the  nitrogen  gas  indicates 
the  quantity  of  urea  in  the  sample. 

Mention  a  chemical  antidote  for  sulphuric  acid  and  ex> 
plain  the  action  of  this  antidote. 

Magnesium  oxide.  It  chemioally  combines  with  sulphuric 
acid  to  form  sulphate  of  magnesium.  This  action  is  accom- 
panied by  the  evolution  of  but  little  heat  and  no  gas,  and  all 
corrosive  properties  of  the  acid  entii-ely  disappear  in  the 
neutralization  which  it  undergoes. 

What  is  fermentation  and  how  is  it  produced?  What 
are  enzymes? 

Fermentation  is  the  decomposition  of  a  complex  body  by 
a  ferment.  For  its  production,  we  require  a  ferment,  moisture, 
presence  of  air  (generally),  and  a  temperature  not  exceeding 
lOO-^  to- 110°  F. 

Enzymes  are  soluble  or  unorganized  ferments  acting  like 
yeast  and  other  organized  ferments.  They  are  of  both  vege- 
t-able  and  animal  origin.  Those  of  animal  origin  are  found 
in  digestive  fluids,  as  pepsin  in  gastric  juice,  ptyalin  in  saliva. 

Differentiate  chemically  sucrose,  glucose,  lactose  and 
maltose. 

►Sucrose,  CjoILaOii,  does  not  reduce  alkaline  cupric  solu- 
tions and  does  not  fennent  with  yeast. 

Glucose,  C9H12O0,  reduces  alkaline  cupric  solutions  ami 
ferments  with  yeast. 

L/actose,  C^z^X^X^n.W^O,  reduces  alkaline  cupric  solutions 
and  does  not  ferment  with  yeast. 

Maltose,  C^2Y[^r.O^^^\2^'  tloes  not  reduce  Barford's  reagent 
(acetic  acid  solution  of  copper  acetate),  otherwise  is  similar 
to  glucose. 


60  CHEMISTRY. 

Complete  the  following  equations: 
FeClg  +  NH^OH  = 
MgCl2+NH,Cl+Na3PO,=. 

FeClg  +  3NH,OH  =  Fe(OH)3  +  SNH^Cl. 

MgCla  +  NH4CI  +  NagPO,  =  NH.MgPO,  +  3NaCl. 

Describe  oxygen  as  to  occurrence,  preparation,  physical 
properties,  chemical  properties,  office  in  the  body. 

Oxygen,  0,  atomic  weiglit  16  (15.88),  valence  II,  occurs  in 
free  state,  forming  about  one-fifth  of  the  atmosphere.  It  is 
found  chemically  combined  with  one-eighth  of  its  weight  of 
hydrogen  in  water  and  is  present  in  many  mineral  and  or- 
ganic compounds.  It  is  the  most  widely  distributed  of  ele- 
mentary substances. 

Prepared  by  heating  a  mixture  of  potassium  chlorate  and 
manganese  dioxide.  Physically,  oxygen  is  a  colorless,  taste- 
less, odorless  gas,  slightly  heavier  than  air.  It  is  soluble  to 
the  extent  of  3  per  cent,  in  water. 

Chemically,  oxygen  supports  combustion,  does  not  bum,  is 
strongly  electro-negative,  is  of  dyad  valency,  combines  chem- 
ically with  all  elements  excepting  fluorine  and  argon. 

It  supports  animal  life;  it  is  carried  by  the  red  blood 
corpuscles  to  every  cell  of  the  body,  upon  wihch  it  acts  de- 
structively to  allow  of  regeneration  of  tissues. 

It  is  used  remedially  where  from  any  cause  respiration  is 
impaired  or  prevented. 

What  is  chlorine?  How  is  it  prepared?  How  is  chlor= 
ine  administered  medicinally  through  the  mouth? 

A  yellowish-green  gas  with  suffocating  odor,  about  21/^ 
times  the  weight  of  air,  soluble  in  water.  Administered  med- 
icinally in  aqueous  solution  known  in  pharmacy  as  liquor 
chlori  compositus,  containing  about  0.4  per  cent,  chlorine. 

Prepared  by  heating  a  mixture  of  manganese  dioxide  and 
hydrochloric  acid,  and  collecting  the  gas  evolved  by  displace- 
ment. 

MnO^  +  4HC1  =  MnCl,  +  2H2O  +  Cl^. 


CHEMISTRY.  61 

Define  alloy,  amalgan.    Give  an  example  of  each. 

An  alloy  is  a  combination  of  two  or  more  metals.  Ex- 
ample: Brass,  an  alloy  of  zinc  and  copper.  An  amalgam  is 
an  alloy  in  which  one  of  the  metals  is  mercury.  Example; 
Tin  amalgam,  composed  of  tin  and  mercury,  used  in  making 
of  mirrors. 

How  is  hydrogen  sulphide  formed  in  nature?  How  is 
hydrogen  sulphide  prepared  in  the  laboratory? 

It  results,  in  nature,  from  the  decomposition  of  organic 
matter  containing  sulphur  in  the  presence  of  moisture.  Ex- 
ample :  The  rotting  of  an  egg  gives  rise  to  hydrogen  sulphide 
from  the  union  of  the  sulphur  in  the  albumen  with  the  hy- 
drogen of  water.  Also  found  in  certain  volcanic  gases  and  in 
some  mineral  waters. 

Hydrogen  sulphide  may  be  prepared  in  the  laboratoi-y  by 
adding  dilute  sulphuric  acid  to  ferrous  sulphide,  as 
FeS  +  H2SO4  =  FeSO,  +  H^S. 

Explain  the  significance  of  the  following  prefixes: 
Hydro,  sub,  hyper,  nitro,  bi. 

Hydro  as  a  prefix  is  used  in  the  naming  of  hydracids,  e.  g. 
Hydrochloric  acid,  HCl. 

Sub  as  a  prefix  is  the  equivalent  of  the  suffix  "  ous,"  sig- 
nifying a  lower  valence  (real  or  apparent)  of  the  positive 
element  in  a  binary  compound  than  is  indicated  by  the  suffix 
"  ic."  It  is  also  used  in  indicating  certain  basic  salts,  e.  g., 
subnitrate  of  bismuth,  BiONOg. 

Hyper  as  a  prefix  is  used  especially  in  indicating  a  greater 
relative  amount  of  oxygen  than  is  contained  in  another  com- 
pound of  the  same  elements. 

Nitro  indicates  the  presence  in  a  compound  of  the  radical 
NO.,  as  C0H5NO2,  nitrobenzene. 

Bi  indicates  two  atoms  of  the  element  so  designated  in 
chemical  combination  with  another  element,  as  CSo,  bi-snl- 
phide  of  carbon. 


62  CHEMISTRY. 

Mention  the  metals  whose  salts  are  often  taken  as 
poisons. 

Silver,  lead,  mercury,  arsenicum,  antimony,  copper,  tin, 
zinc,  barium. 

What  is  common  salt?  State  where  and  how  common 
salt  is  obtained,  and  give  the  chemistry  of  its  use  for 
freezing  purposes. 

Sodium  chloride,  NaCl.  Obtained  by  evaporation  of  sea 
water,  and  from  salt  deposits. 

When  salt  is  mixed  with  snow  or  ice  it  occasions  a  rapid 
melting — heat  is  rendered  latent,  such  heat  being  extracted 
from  neighboring  bodies. 

Explain  the  formation  of  a  vesical  calculus  having  a  uric 
acid  nucleus. 

An  aggregation  of  uric  acid  crystals,  from  their  sharp 
angular  character,  irritate  the  vesical  mucous  lining,  so  that 
they  become  surrounded  with  mucus,  and  then,  from  inflam- 
mation produced,  we  may  have  decomposition  of  urine,  with 
aocompanying  deposition  of  alkaline  urates,  or  phosphates, 
around  the  original  mass. 

Give  two  tests  for  morphine. 

Touclif^the  suspected  alkaloid  with  nitric  acid,  and  if  it  be 
morphine,  it  dissolves,  yielding  an  orange-red  liquid  that  soon 
fades  to  yellow. 

To  morphine  add  neutral  ferric  chloride  solution — a  blue 
color  is  produced. 

When  are  substances  said  to  (a)  isomeric,  (b)  meta= 
meric,  (c)  polymeric? 

Substances  are  isomeric  when  they  are  made  up  of  the 
siame  elements  in  the  same  percentage  proportion. 

Two  or  more  bodies  are  metameric  when  composed  of  the 
same  elements  in  the  same  percentage  composition  and  when 
they  have  the  same  molecular  weight. 

Polymeric  bodies  are  composed,  of  the  same  elements  in  the 


CHEMISTRY.  68 

same   percentage    composition   but    with    different   molecular 
weights. 

Write  a  reaction  for  making  barium  sulphate  from 
sodium  sulphate.  How  many  grams  of  sodium  sulphate 
are  required  to  yield  2.33  grams  of  barium  sulphate  by 
this  process?     (Atomic  weight  of  barium  equals  37.) 

Na^SO,  +  BaCl^  =  BaSO,  +  2NaCl. 
142Na,S04  make  233  of  BaSO,. 

If  233   grams  of  barium  suJphate   require   142   grams  of 
sodium  sulphate,  then  233  :  142  : :  2.33  :  X,  or  1.42. 
Result,  1.42  grams  of  sodium  sulphate  required. 

Describe  and  illustrate  (a)  monobasic  acid,  (b)  dibasic 
acid,  (c)  tribasic  acid. 

(a)  An  acid  containing  one  atom  of  hydrogen  capable  of 
being  replaced  by  a  metal  or  an  electro-positive  radical,  as 
HCoH-jOs,  acetic  acid ;  AgC^ILjOo,  argentic  acetate. 

(b)  An  acid  which  contains  two  replaceable  hydrogen 
atoms  in  each  molecule,  as  TTjSO^,  snlphuric  acid;  NajSO^, 
Hodium  sulphate. 

(c)  An  acid  which  contains  three  replaceable  hydrogen 
atoms  in  each  molecule,  as  H.^PO^.  phosphoric  acid;  NajPO^^ 
normal  sodium  phosphate. 

Write  chemical  equations  showing  two  methods  of  ob- 
taining hydrogen. 

Zn  -h  11,,S0,  =  ZnSO,  +  H^. 
Zn  +  2K0II  =  KoZnO.,  +  TL. 

What  is  the  meaning  of  the  words  monad,  tetrad  and 
pentad?     (iive  an  example  of  each. 

Monad  refei-s  to  an  element  or  conipound  rcdical  Avhose 
power  of  combination  is  the  siuuo  as  that  of  hydrogen.  Tims 
chlorine  is  a  moujid.  one  atom  of  II  uniting  with  one  atom  of 
chlorine. 

Tetrad  is  an  clement  or  compound  radical  exhibiting  a 
combining  [jower  four  times  that  possesse<I  by  hydrogen. 
Kxamp)le:  Carbon,  as  in  marsh  gas.  Vl\^. 


64  CHEMISTRY. 

A  pentad  has  a  combining  power  equal  to  five  times  that 
of  hydrogen.  Example:  Phosphorus,  in  its  compound  phos- 
phorus pentachloride,  PCI5. 

Describe  cyanogen  and  its  principal  compounds. 

Cyanogen,  symbol,  Cy  or  CN. 

This  body  is  an  organic  compound  radical  composed  of 
equal  volumes  of  carbon  and  nitrogen  vapors.  It  is  a  color- 
less, inflammable  gas,  soluble  in  water.  It  exists  in  many 
vegetable  structures,  is  electro-negative  or  acidulous,  of 
monad  valency,  and  resembles  chlorine  in  chemical  compounds 
which  it  forms. 

Important  compounds.:  Hydrocyanic  acid,  HON.  A  very 
volatile  liquid  with  eharacteristic  odor  used  in  dilute  aqueous 
solution.  Very  poisonous.  KCN,  potassium  cyanide,  a  white, 
deliquescent,  poisonous  solid.  Potassium  ferro-eyanide  and 
potassium  ferri-cyanide  have  considerable  use  in  arts  and 
manufactures  and  as  chemical  reagents.  Nickel,  silver  and 
gold  cyanides  are  all  used  for  electro-plating  purposes. 

What  are  the  source  and  principal  properties  of  vase- 
line? 

Vaseline  is  obtained  by  purifying  the  residue,  after  dis- 
tilling the  more  volatile  substances  from  petroleum. 

It  is  a  more  or  less  fluorescent,  unctuous  solid,  melting  at 
from  104  to  125  degrees  Fahr.  It  is  almost  odorless  and 
tasteless. 

Give  the  general  characteristics  of  the  aluminum  group 
of  elements. 

Metals  of  aluminum  group  include  aluminum,  indium,  gal- 
lium, and  others  still  less  common.  They  form  compounds  of 
the  type  MCI3  or  MoOg.  Their  oxides  are  weak  bases;  their 
sulphates,  with  the  sulphates  of  alkali  metals,  form  double 
salts  called  alums,  which  crystallize  in  the  regular  isometrie 
system. 

The  oxides  and  hydroxides  are  insoluble  in  water,  as  ai-e 
also  the  phosphates  and  carbonates. 


CHEMISTRY.  65 

Give  a  typical  example  of  each  of  the  following  classes 
of  mineral  waters:  (a)  Saline  cathartic,  (b)  alkaline,  (c) 
sulphurous. 

(a)  Carlsbad,  containing  sodium  magnesium  sulphates. 

(b)  Vichy,  containing  sodium  bicarbonate. 

(c)  Richfield  spring,  containing  hydrogen  sulphide. 

Describe  one  of  the  processes  by  which  HCI  and  N  may 
be  prepared. 

HCI  is  prepared  by  heating  sulphuric  acid  with,  common 
salt  and  passing  the  evolved  gas  into  water. 

N  is  prepared  by  passing  air  over  incandescent  copper,  the 
metal  uniting  with  the  oxygen  present. 

Explain  the  difference  between  the  Fahrenheit,  centi= 
grade  and  Reaumur  thermometers. 

The  freezing-point  of  water  in  the  Fahrenheit  scale  is  placed 
at  32  degrees,  while  in  the  Centigrade  and  Reaumur  scales 
this  point  is  made  zero.  The  boiling-point  in  the  Fahrenheit 
scale  is  212  degrees,  the  Centigrade  scale  100  degrees,  Reau- 
mur 80  degrees.  Between  the  freezing  and  boiling  points  of 
water  in  the  F.  scale  we  have  180  degrees,  in  C.  scale  100,  in 
R.,  80.  Hence  each  degree  F.  would  correspond  to  Vo  of  a 
degree  C.  and  Vj,  of  a  degree  R. 

What  is  litmus?     Explain  its  uses  in  urinalysis. 

Litmus  is  a  vegetable  substance  obtained  from  a  species  of 
lichen. 

In  urinalysis  we  use  it  generally  in  the  fonn  of  litmus 
paper  (paper  impregnated  with  an  aqueous  solution  of  lit- 
mus) to  determine  the  reaction  of  urine.  Blue  litmus  is  red- 
dened by  acids;  red  litmus  is  turned  to  a  blue  by  alkalies, 
permanently  if  the  alkalies  be  fixed,  transiently  (removable 
by  warming)  if  the  alkali  be  volatile. 

Give  the  chemical  differences  between  chloral  and  chlo- 
roform. 

Chloral    is    formed    from   aldehyde    by   substituting    three 
5 


66  CHEMISTRY. 

chlorine  atoms  for  three  hydrogen  atoms;  aldehyde,  CH3COH ; 
chloral,  CCI3COH. 

Kjaown  chemically  as  trichloraldehyde. 

Chlorofoi-m  is  trichlonnethane,  or  marsh  gas  in  which 
three  hydrogen  atoms  have  been  replaced  'by  chlorine  atoms; 
marsh  gas,  CH^ ;  chloroform,  CHCI3. 

Complete  the  following  equations: 
CaCl,  4-  (NH,)2C03  = 
CH^N^O  +  ^H^O^ 

CaCls  +  (NHJ2CO3  =  CaC03  +  2NH,C1. 
CH.N^O  +  2H2O  =  (NHJXO3. 

Define  malleability,  endosmosis. 

Malleability  is  that  property  by  virtue  of  which  certain 
metals  may  be  hammered  or  rolled  out  into  thin  sheets.  En- 
dosmosis refers  to  the  passage  of  a  liquid  of  a  certain  density 
inward  through  a  porous  partition  to  mix  with  a  liquid  of 
different  density. 

Give  the  general  characteristics  of  rain  water,  well 
water,  river  water,  and  lake  water. 

Rain  water,  a  soft  water,  containing  gases  dissolved  from 
the  atmosphere  but  only  a  small  amount  of  solids.  Well 
water,  character  depends  upon  depth  and  location  of  well, 
upon  surrounding  conditions,  nature  of  soil,  etc.  River  water 
depends  upon  source  and  exposure  to  contamination — sewage, 
manufacturing  waste,  geological  conditions.  Lake  water  is 
similar  to  river  water,  depending  upon  conditions  for  its 
purity  or  contamination. 

Give  the  method  of  preparation  and  the  special  charac= 
teristics  of  ozone. 

-  It  may  be  prepared  by  passing  electric  discharges  through 
moist  air  or  oxygen  or  by  the  slow  oxidation  of  moist  phos- 
phorus. 

Ozone  is  a  bluish  gas  with  irritating  effect  upon  respiratory 
mucous  surfaces ;  it  is  an  active  oxidizing  agent. 

Test:  Paper  saturated  with  a  mixture  of  starch  mucilage 


CHEMISTRY.  C7 

and  potassium  iodide  solution  will  be  turned  blue  by  contact 
with  ozone. 

What  is  flourine  and  where  is  it  obtained?  State  the 
preparation  and  the  practical  uses  of  hydrofluoric  acid. 

Fluorine,  F,  atomic  weight  19  (18.9),  valence  I,  a  nearly 
colorless  gas,  the  first  one  of  the  halogen  series  of  elements, 
occure  in  nature  in  combination  with  metals  as  fluorides, 
e.  g.,  calcium  fluoride  or  fluorspar,  CaFj. 

Hydrofluoric  acid  is  made  by  heating  calcium  fluoride  and 
sulphuric  acid  in  a  leaden  vessel  and  passing  the  evolved  gas 
into  water,  in  which  it  readily  dissolves.  Its  chief  use  is  as 
a  solvent  for  glass,  used  for  etching,  etc. 

What  are  the  constituent  parts  of  boroglycerid  and  what 
is  its  use  in  medicine? 

Boric  acid  and  glycerin.  U.  S.  P.  Glyceritum  boroglycer- 
ini,  31  per  cent,  boric  acid  dissolved  in  glycerin.  It  is  anti- 
septic and  detergent. 

What  are  the  properties  of  lead?  What  is  litharge? 
Give  the  toxicology  of  lead. 

Lead,  Pb,  atomic  weight  205  (205.33),  valence  II;  a  soft, 
heavy,  bluish-white  metal,  tarnisbes  rapidly  on  exposure  to 
air.  Melts  at  325°  C. ;  sp.  gr.  11.37 ;  oxidizes  when  heated 
in  air  to  form  yellow  oxide  of  lead  or  litharge.  Soluble  in 
nitric  acid,  in  acetic  acid,  in  very  strong  hot  sulphuric  acid. 

Litharge  is  monoxide  of  lead,  PbO. 

Lead  may  occasion  acute  or  chronic  poisoning.  In  acute 
lead  poisoning  we  have  the  action  of  an  irritant — vomiting, 
abdominal  cramps,  constipation.  Chronic  lead  poisoning,  as 
it  occurs  in  painters  or  in  those  constantly  exposed  to  the 
fumes  of  lead  and  its  compounds,  is  characterized  by  anemia, 
obstinate  constipation,  abdominal  colic,  paralysis  of  extensor 
muscles,  producing  "  wrist-drop  "  and  many  obscure  nervous 
symptoms,  paralyses,  anesthesias,  etc.  Antidotes:  magnesium 
sulphate  and  sodium  sulphate. 


68  r.HEMISTRY. 

Give  the  preparation,  formula  and  characteristics  of 
bromide  of  ammonium. 

Ammonium  bromide,  NH^Br.  Place  one  pound  of  bromine 
in  a  stone  jar,  add  to  it  carefully  four  times  its  weight  of 
water,  then  add  half  ounce  at  a  time,  very  slowly,  one  quart 
of  ammonia. 

6Br  +  8NH3  =  6NH,Br  +  N^. 

It  is  a  white  crystalline  salt,  saline  taste,  permanent  in  air, 
soluble  in  water;  heated  with  caustic  soda  evolves  odor  of 
ammonia.  Passing  chlorine  gas  through  its  water  solution 
bromine  is  disengaged. 

Ammonium  bromide  acts  upon  the  system  as  a  depressant 
to  the  motor  function  of  spinal  cord.  Its  chief  uses  are  to 
produce  sleep  and  allay  nervous  irritability. 

Give  a  description  of  the  preparation  and  mention  the 
properties  of  the  principal  alcoholic  beverage  obtained 
from  the  fermentation  of  malted  grains. 

The  brewer  "  mashes  "  the  ground  malt  with  water,  and 
heats  at  aJbout  180  degrees  F.  for  several  hours,  when  such 
starch  as  has  not  been  already  changed  by  germination  of  the 
grain  is  now  converted  into  dextrin  and  sugar. 

The  resulting  liquid,  "  wort,"  is  boiled  with  hops  and  the 
mixture  is  allowed  to  stand,  yeast  is  added,  and  the  liquid 
fermented.  Glucose  is  changed  to  alcohol,  with  a  further 
formation  in  the  liquid  of  traces  of  lactic,  succinic,  carbonic 
and  acetie  acids,  glycerin,  etc. 

The  fermentative  process  is  finally  stopped  by  heating  the 
liquid. 

Ale,  porter,  stout  and  beer  differ  only  in  the  selection  and 
proportion  of  the  malt,  hops  and  flavoring  material.  They 
vary  in  alcoholic  eontent  from  1  to  10  per  cent,  with  an  aver- 
age of  4  to  5  per  cent.,  ales  and  stouts  being  generally  richer 
in  both  extractives  and  alcohol  than  are  the  beers. 

What  is  the  normal  amount  of  uric  acid  excreted  in  24 


CHEMISTRY.  69 

hours  by  an  adult,  and  what  effect  has  diet  on  the  quantity 
so  excreted? 

From  0.3  to  0.8  grammes  in  24  hours.  Increased  by  a  diet 
rich  in  nitrogen,  as  of  meats,  peas,  beans,  eggs,  etc.,  and  by 
alcoholic  beverages. 

What  is  the  fever  thermometer?  How  is  it  made  and 
graded? 

A  small  glass  thermometer  of  a  minute  capillary  bore,  with 
a  constriction  in  the  lumen  immediately  above  the  mercurial 
chamber.  The  mercury,  in  its  expansion,  passes  up  the  tube, 
but  on  cooling  and  contracting  cannot,  by  its  own  weight,  fall 
down  past  the  constricted  portion. 

The  steps  of  manufacture  are  calibrating  the  tube,  filling 
and  curing  the  tube,  and  finally  graduating  the  finished  in- 
strument. The  scale  is  generally  from  90  degrees  Fahr.  to 
110  degrees  Fahr.,  each  degree  being  subdivided  into  five 
equal  parts. 

Give  a  general  description  of  the  alkaloids. 

The  alkaloids  are  organic  nitrogenous  substances,  basic  in 
character,  capiable  of  combining  directly  with  acids  to  form 
salts.  They  are  commonly  divided  into  two  groups:  (1) 
Liquid  or  Volatile  alkaloids,  containing  carbon,  hydrogen  and 
nitrogen.  (2)  Fixed  or  Non-Volatile  alkaloids,  containing 
carbon,  hydrogen,  nitrogen  and  oxygen.  Most  alkaloids  are 
insoluble  or  only  slightly  soluble  in  water;  more  soluble  in 
alcohol,  chloroform  and  benzene.  The  salts  of  the  alkaloids, 
on  the  other  hand,  are  generally  soluble  in  water  and  in 
alcohol  and  less  soluble  in  chloroform  and  benzene. 

How  are  soaps  prepared?  Give  a  chemical  classification 
of  soaps. 

Soaps  are  prepared  by  decomposing  fat  with  an  alkali  or 
other  metallic  base,  this  process  being  known  as  saponification. 
Sodium  soaps,  salts  of  fatty  acids  with  sodium,  are  hard 
Boaps.  Potassium  soaps,  salts  of  fatty  acids  with  potassium, 
are  eof  t  soaps. 


70  CHEMISTRY. 

Describe  two  methods  of  disinfection  by  chemical 
agents. 

Sulphur  may  be  burned,  the  room  having  been  closed  and 
all  fabrics  liable  to  be  injured  by  the  acid  fumes  removed. 
Sulphur  dioxide  is  formed  by  the  burning  of  the  sulphur  and 
this,  in  union  with  water  (moisture),  forms  sulphurous  acid. 

Or  the  room  or  material  may  be  exposed  to  the  prolonged 
action  of  formaldehyde,  this  having  an  advantage  over  sul- 
phur burning  in  that  it  has  no  corrosive  or  bleaching  action. 

Give  the  names  and  formulas  of  three  substances  used 
for  disinfecting  purposes.  Explain  the  chemical  action 
that  maizes  any  one  of  these  substances  valuable  as  a 
disinfectant. 

Sulphur,  S,  burned  in  the  air  producing  sulphur  dioxide, 
SO2. 

Chlorine,  CI,  which  may  be  given  off  from  bleaching  pow- 
der, CaOCla. 

Formaldehyde,  HCOH. 

Chlorine  acts  as  a  disinfectant,  because  of  its  affinity  for 
hydrogen  and  its  indirect  oxidizing  action  upon  organic 
matter. 

State  the  usual  source  and  give  the  properties  of  (a) 
tannic  acid,  (b)  tartaric  acid. 

^Tannic  acid  is  obtained  from  oak-bark  and  from  nutgalls. 
It  occurs  as  a  light-yellowish  amorphous  powder,  gradually 
darkening  on  exposure  to  light  and  air.  It  is  odorless  or  with 
a  faint  characteristic  odor,  and  a  strongly  astringent  taste. 
Soluble  in  water,  the  solution  giving  a  blue-black  precipitate 
with  ferric  salts. 

Tartaric  acid  is  obtained  from  argol,  the  impure  cream  of 
tartar  deposited  during  the  fermentation  of  grape  juice.  It 
is  also  made  synthetically.  It  forms  in  large  crystals,  perma- 
nent in  air,  soluble  in  water  and  in  alcohol,  insoluble  in  ether. 


CHEMISTRY.  71 

Define  (a)  alcohol,  (b)  aldehyde,  (c)  carbohydrate. 

(a)  An  alcohol  is  a  compound  of  a  hydrocarbon  radical 
with  hydroxyl.  (b)  An  aldehyde  is  a  compound  of  a  hydro- 
carbon radical  with  the  group  COH.  They  are  formed  by 
oxidation  of  primary  alcohols,  (c)  A  carbohydrate  may  be 
described  as  a  compound  of  carbon,  hydrogen  and  oxygen — 
in  which  the  hydrogen  and  oxygen  atoms  are  as  two  to  one. 
The  carbohydrates  are  derivatives  of  the  hexatomic  alcohols. 

Give  the  details  of  procedure  in  examining  the  stomach 
in  a  case  of  death  from  suspected  poisoning  by  arsenic. 

Ligate  the  stomach  and  remove,  with  contents,  from  the 
body.  Open  and  place  contents  in  a  clean  vessel.  Spread 
stomach  on  plate  of  clean  glass  and  examine  mucus  mem- 
brane for  evidence  of  inflammation  and  for  particles  of  un- 
dissolved poison.  The  analysis  of  the  stomach  or  of  its  con- 
tents is  prepared  for  as  follows:  The  solid  matter  is  finely 
divided  and  heated  on  a  water-bath  with  diluted  hydro- 
chloric acid.  Potassium  chlorate  is  added  from  time  to  time 
until  the  organic  matter  is  destroyed.  The  liquid  is  now 
filtered,  the  excess  of  chlorine  removed,  and  the  special  ar- 
senical tests  applied. 

Describe  human  milk  as  to  (a)  composition,  (b)  reac- 
tion, (c)  specific  gravity. 

(a)  Human  milk  contains  (Frankland)  on  an  average  of 
11.4  per  cent,  solids,  divided  as  follows:  Proteids,  2.7;  fat, 
3.5;  lactose,  5.0;  salts,  0.2.  Compared  with  cow's  milk,  this 
is  rather  lower  in  total  solids,  lower  in  proteids,  slightly  lower 
in  fat,  higher  in  lactose  and  lower  in  salts. 

(b)  Human  milk  is  normally  faintly  alkaline  in  reaction, 
with  a  (c)  specific  gravity  averaging  1030-81.  but  varying 
from  1024  to  1034. 

State  the  source  and  give  the  chemical  composition  of 
any  one  of  the  following:  (a)  pepsin,  (b)  ptyalin,  (c) 
bilirubin. 

Bilirubin  is  the  principal  pigment  of  the  bile.  It  has  the 
composition  CiqH,,Nj03. 


72  CHEMISTRY. 

What  are  the  common  constituents  of  urinary  calculi? 

Urinary  calculi  may  consist  of  uric  acid  and  urates,  of  cal- 
cium oxalate,  ammonium  oxalate,  and,  more  rarely,  of  phos- 
phates, carbonates,  etc.  Often  two  or  more  of  these  sub- 
stances are  present. 

Give  the  chemical  reaction  of  (a)  tears,  (b)  bile,  (c) 
blood,  (d)  saliva,  (e)  milk. 

(a)  Neutral,  (b)  (e)  (d)  Alkaline,  (e)  Alkaline  when 
secreted,  becoming  acid  on  exposure  to  air  and  standing. 

What  chemical  changes  occur  in  milk  which  render  it 
unsafe  as  a  food  or  as  a  beverage? 

The  question  is  obscure.  On  standing  milk  is  rapidly  con- 
taminated with  bacteria,  some  of  which  may  bring  about  a 
conversion  of  the  lactose  into  lactic  acid  and,  later,  butyric 
acid.  Or,  more  seriously,  from  unsanitary  storage,  ptomaines 
may  develop. 

What  chemical  changes  takes  place  in  milk  when  it  be- 
comes acid?     Detail  a  test  for  its  detection. 

By  the  action  of  the  bacterium  lactis  the  lactose  is  changed 
into  lactic  acid  land  by  the  action  of  this  acid  the  milk  sepa- 
rates into  a  curd,  consisting  chiefly  of  oaseinogen,  and  a 
liquid,  acid  whey.  As  a  result  of  further  decomposition 
butyric  acid  is  produced. 

Describe  a  chemical  test  for  one  of  the  adulterants  of 
milk. 

Hehner's  test  for  formaldehyde:  Dilute  the  milk  with  an 
equal  volume  of  water  and  float  it  over  90-94  per  cent,  sul- 
phuric acid,  the  latter  containing  a  trace  of  a  ferric  salt.  If 
formaldehyde  be  present  a  violet  ring  is  formed  at  the  junc- 
tion of  the  two  liquids;  in  absence  of  formaldehyde  the  ring 
has  a  greenish  tinge. 

What  is  the  relative  importance  of  the  element  carbon 
in  organic  chemistry? 

All  organic  compounds  contain  carbon.  It  is  the  essential 
element  whose  presence  classes  the  body  as  organic. 


CHEMISTRY.  73 

In  testing  urine  by  heat  in  a  case  of  suspected  albu^ 
minuria,  what  substances  might  be  precipitated  and  so 
make  the  test  deceptive? 

Phosphates  of  calcium  and  magnesium. 

Describe  the  chemical  process  (a)  when  iron  rusts,  (b) 
when  wood  burns,  (c)  when  silver  is  tarnished  by  coal  gas. 

(a)  The  rusting  of  iron  is  an  oxidation  process,  the  final 
product  being  ferric  hydroxide,  Fe2(OH)8. 

(b)  Wood  burns  to  form  carbon  dioxide  and  water. 

(c)  Silver,  in  presence  of  coal  gas,  becomes  coated  with^ 
black  sulphide  of  silver,  AgS,  from  the  presence  in  the  coal 
gas  of  sulphur  compounds. 

Describe  the  manufacture  of  illuminating  gas. 

Coal  gas  process :  Bituminous  coal  is  subjected  to  destruc- 
tive distillation  in  retorts,  the  gaseous  product  being  then 
successively  cooled  to  remove  the  less  volatile  tar,  washed 
with  water  to  remove  ammonia,  and  passed  through  lime  to 
remove  the  sulphur  compounds. 

Water  gas  process:  Air  and  steam,  alternately,  are  passed 
over  red-hot  coke  or  anthracite  coal. 

Cj-f  2H20  =  2C0  4-2H2. 
The  gas  produced  is  given  illuminating  value  by  enriching 
with  naphtha. 

Mention  the  antidotes  applicable  in  cases  of  poisoning 
from  (a)  caustic  alkalies,  (b)  carbolic  acid. 

(a)  Vinegar,  lemon  juice,  oils,  fats,  mucilaginous  drinks. 

(b)  Soluble  sulphates,  as  sodium  or  magnesium  sulphate, 
oils,  fats,  albumin,  vinegar,  and  alcohol. 

Where  is  oxygen  found  in  the  human  body  and  what 
are  its  important  uses  in  the  animal  economy? 

It  is  pre*ient  in  all  animal  tissues  and  fluids.  Oxygen  is 
necessary  for  the  oxidation  and  removal  of  existing  tissues, 
with  subsequent  replacement  by  new  structures.  It  is  only 
through  the  ingestion  of  oxygen,  in  respiration,  that  animal 
life  is  maintained. 


74  CHEMISTRY. 

When  sulphur  is  burned  in  the  air,  what  is  the  product 
and  what  are  its  uses? 

Sulphur  dioxide  or  sulphurous  anhydride,  SOg. 

It  bleaches  organic  colors,  is  a  disinfectant,  and  stops  or 
limits  fermentation.  In  the  arts  it  is  used  for  the  manufac- 
ture of  sulphuric  acid  and  other  chemicals. 

Write  the  formulas  for  (a)  sodium  sulphate,  (b)  potas= 
sium  nitrate,  (c)  ammonium  chloride. 

(a)  Na^SO,.     (b)  KNO^.     (c)  NH.Cl. 

Describe  the  method  of  obtaining  H  and  O  by  passing 
an  electric  current  through  HgO,  and  tell  how  to  deter= 
mine  which  gas  is  O. 

Seal  two  platinum  wires  in  the  opposite  sides  of  a  glass 
flask,  solder  two  upright  strips  of  platinum  to  these  entering 
horizontal  wires.  Connect  one  of  the  entering  wires  with  the 
positive  pole  of  a  galvanic  battery  of  several  cells  and  the 
other  wire  with  the  negative  pole.  Place  in  flask  water  ren- 
dered faintly  acid  with  sulphuric  acid,  and  invert  two  test- 
tubes,  filled  with  this  same  acidified  water,  over  the  platinum 
terminals.  Pass  the  current  and  gas  will  accumulate  in  both 
tubes,  the  oxygen  with  half  the  rapidity  of  tlie  hydrogen. 
The  gas  may  be  further  identified  by  plunging  into  it  a  frag- 
ment of  glowing  wood,  which  will  be  kindled  to  a  brilliant 
flame  by  the  oxygen. 

What  is  effervescence  and  what  is  efflorescence? 

Effervescence  refers  to  the  bubbling  off  of  a  gas,  e.  g.,  the 
escape  of  carbon  dioxide  on  treating  a  carbonate  with  an  acid. 

Efifloreseence  refers  to  the  loss  of  water  of  crystallization 
which  certain  crystals  undergo  when  exposed  to  air.  They 
dry  out,  become  powdery  and  lose  their  crystalline  form. 

What  changes  take  place  in  alcoholic  fermentation? 

G-lucose  is  converted  into  alcohol  and  carbon  dioxide  gas: 
CeHi^O,  =  2C,H50H  -f  2C0,. 


CHEMISTRY.  75 

What  is  understood  by  specific  gravity,  and  what  pre= 
cautions  are  advisable  in  the  use  of  the  urinometer? 

(a)  By  specific  gravity  of  a  substance  we  mean  the  ratio, 
or  relation  by  weight,  the  substance  bears  to  the  weight  of 
an  equal  volume  of  some  substance  used  as  a  standard, 

(b)  The  temperature  of  the  liquid  to  be  examined  should 
correspond  with  the  temperature  for  which  the  instrument  is 
graduated,  otherwise  a  correction  should  be  made.  The  in- 
strument should  be  free  of  any  adhering  bubbles.  The  urino- 
meter tube  should  be  filled  to  the  brim. 

Give  the  chemical  name  and  formula  of  (a)  water,  (b) 
common  salt,  (c)  carbonic  acid,  (d)  nitric  acid. 

(a)  Hydrogen  monoxide,  HgO.  (b)  Sodium  chloride, 
NaCl.  (c)  Carbonic  acid  or  hydrogen  carbonate,  H2CO3. 
(d)  Nitric  acid  or  hydrogen  nitrate,  HNO3. 

How  does  fire°-damp  explode  in  mines? 

When  marsh  gas  escapes  from  fissures  in  coal  foinnations 
and  mixes  with  air,  it  explodes  with  violence  on  contact  with 
a  naked  flame  or  spark,  the  chemical  results  being  carbon 
dioxide  and  water. 

If  the  proportion  of  air  rises  to  18  times  the  volume  of 
marsh  gas  no  explosion  occurs. 

Demonstrate  the  fact  that  air  is  a  mixture,  and  not  .1 
compound. 

Pass  air  thi-ough  water  that  has  been  boiled,  and  3  per 
cent,  of  the  oxygen  of  the  air  will  be  retained  dissolved  in 
the  water,  while  less  than  1  per  cent,  of  nitrogen  will  be  re- 
tained by  the  water. 

What  is  the  chemical  antidote  in  case  of  poisoning  by 
tartar  emetic? 

Tannic  acid. 

What  is  the  formula  of  sulphuretted  hydrogen?  What 
are  some  of  its  properties  and  uses? 

Sulphuretted  hydrogen,  ILS,  is  a  colorless  gas,  slightly 
heavier  than  air*,  of  a  di.sgusting  charaoteri.stic  odor.     Bums 


76  CHEMISTRY. 

wilh  a  blue  flame  when  ignited,  forming  sulphur  dioxide  and 
water. 

It  is  used  as  a  group  reagent  to  precipitate  metals  of  the 
so-called  second  analytical  group. 

Which  metal  is  (a)  the  least  tenacious,  (b)  the  most 
infusible,  (c)  the  best  for  electro=magnets,  (d)  the  best 
for  electro=conductors,  (e)  the  most  rare? 

(a)  Mercury;  (b)  osmium;  (c)  iron;  (d)  silver;  (e)  ra- 
dium. 

Describe  the  process  for  the  preparation  of  nitric  acid. 

Prepared  by  the  action  of  sulphuric  acid  on  sodium  nitrate 
in  glass  or  cast-iron  retorts. 

NaNOg  +  H^SO,  =  NaHSO,  +  HNO3. 

Give  the  flame  test  for  barium  and  strontium. 

Moisten  a  clean  platinum  wire  with  hydrochloric  acid,  and 
dip  it  into  the  powdered  barium  salt;  hold  the  wire  in  the 
Bunsen  flame,  a  green  color  will  be  obtained. 

Strontium,  under  like  conditions,  will  give  a  brilliant  red 
color. 

What  is  the  per  cent,  of  each  constituent  present  in 
sulphuric  acid,  the  atomic  weight  of  sulphur  being  32? 

The  molecular  weight  of  H2SO4  is  98.  In  98  parts,  then, 
of  H2SO4  there  are,  hydrogen  2  parts,  sulphur  32  parts, 
oxygen  64  parts. 

In  100  parts  there  will  be,  of  hydrogen  (2^98)  X  100  = 
2.04  per  cent. ;  of  sulphur  (32  ^  98)  X  100  =  32.65  per  cent. ; 
of  oxygen  (64-f-98  X  100  =  65.31  per  cent. 

What  are  principal  constituents  of  milk? 

Water,  fats,  sugar  (lactose),  proteids  including  caseinogen 
and  milk  albumin,  and  mineral  salts,  chiefly  phosphates  and 
chlorides  of  calcium,  magmesium,  sodium  and  potassium. 

To  what  impurity  is  the  occasional  toxic  effect  of  bis- 
muth salts  due? 

Arsenic, 


CHEMISTRY.  77 

Give  the  chemical  reason  why  diabetics  should  abstain 
from  starchy  foods. 

Because  of  the  eonverison  of  starch  into  glucose  through 
the  action  of  ptyalin  in  saliva,  and  amylopsin  in  pancreatic 
juice.  Glucose  thus  formed  cannot  be  broken  up  into  other 
substances  because  of  loss  of  power  of  body  cells  to  etfect  the 
change,  so  that  this  glucose  passes  directly  into  the  blood, 
from  which  it  is  eliminated  by  the  kidneys. 

What  chemical  changes  take  place  as  a  result  of  mus- 
cular activity? 

Oxidation  of  tissue  substance  with  increased  formation  and 
elimination  of  urea  from  decomposed  nitrogenous  structures. 
Increased  rapidity  of  circulation  brings  formative  material 
to  quickly  repair  this  loss  or  waste,  so  that  tissues  are  rapidly 
destroyed,  rapidly  replaced,  and  the  waste  rapidly  removed 
through  exercise. 

What  is  the  difference  between  fermentation  and  putre- 
faction? 

Fermentation  is  the  decomposition  of  a  complex  substance 
by  the  action  of  a  ferment. 

The  term  putrefaction  is  commonly  applied  to  the  decom- 
position of  nitrogenous  bodies  by  the  action  of  bacteria. 

Mention  the  antidotes  applicable  in  a  case  of  poisoning 
from  iodine. 

Starch,  mucilaginous  drinks,  flour,  milk,  white  of  egg. 

Describe  chloral  hydrate. 

Chloral  hydrate,  CCI3COH.H2O. 

A  colorless,  transparent,  crystalline  solid,  pungent  odor, 
acrid  taste,  very  soluble  in  water.  It  liquefies  if  triturated 
with  camphor  or  menthol.     Is  used  as  a  hypnotic. 

Give  a  chemical  explanation  of  the  souring  and  curdling 
of  milk. 

A   fenneu't  acts   upon   the  sugar  of   milk   changing   it   to 


78  CHEMISTRY. 

lactic  acid;  this  lactic  acid  then  produces  a  sour  taste  and 
coagulates  the  casein. 

Name  each  of  the  following  (a)  HjSOa,  (b)  HgSOg,  (c) 
M2SO,,  (d)  H2S2O3. 

(a)  Hyposulphurous  acid;  (b)  sulphurous  acid;  (c)  sul- 
phuric acid;  (d)  thio-sulphuric  acid  (from  which  the  class 
of  salts  commonly  known  as  hyposulphites  is  obtained) . 

What  are  the  chemical  constituents  of  biliary  calculi? 

Cholesterin,  pigments,  biliary  acids,  mucus,  epithelium,  car- 
bonate of  calcium,  fats. 

Describe  your  mode  of  procedure  in  making  a  chemical 
examination  of  suspected  urine. 

Ascertain  quantity  passed  in  24  hours  and  obtain  an  aver- 
age specimen.  Note  color,  appearance  and  odor.  Test  the 
reaction  with  litmus  paper  and  take  the  specific  gravity. 
Filter  the  urine  and  test  for  albumin  by  heat  or  nitric  acid 
tests,  and  for  sugar  by  Fehling's  or  Haines'  tests.  Deter- 
mine the  amount  of  urea  by  the  hypobromite  method.  Test 
for  chlorides  with  acidified  silver  nitrate,  for  sulphates  with 
acidified  barium  chloride,  and  for  phosphates  with  magnesia 
mixture.  Test  for  indican  by  use  of  concentrated  hydro- 
chloric acid. 

Describe  the  theory  of  the  construction  of  the  metric 
system. 

The  metre,  unit  of  linear  measure,  is  the  one  ten-millionth 
of  a  quadrant  of  a  great  circle  of  the  earth.  The  metre  is 
39.37  inches  in  length.  It  is  divided  into  ten  equal  parts 
called  decimetres. 

Each  decimetre  is  divided  into  ten  equal  parts  called  cen- 
timetres. 

Each  centimetre  divided  into  ten  parts  called  millimetres. 

Ten  metres  measure  one  dekametre;  ten  dekametres  equal 
one  hectometre ;  ten  hectometres  equal  one  kilometre. 

A  cubic  centimetre  of  distilled  water,  at  four  degrees  Cent., 
weighs  one  gramme,  the  unit  of  weight  equaling,  in  the  Eng- 
lish system.  15.432  troy  grains. 


CHEMISTRY.  79 

The  gramme  is  divided  and  subdivided,  like  the  metre,  into 
deei-,  centi-,  millegrammes,  and  we  also  have  the  multiples, 
deka-,  hecto-,  kilogrammes,  referring  respectively  to  10,  100 
and  1000  grammes. 

A  cubical  vessel  with  a  length  of  side  of  one  decimetre 
holds  one  litre  of  liquid,  the  measure  of  capacity.  A  litre 
contains  1000  cubic  centimetres,  and  is  nearly  equal  to  the 
English  quart. 

Wherein  do  wine,  beer  and  whiskey  differ? 

Wine  is  a  fermented  fruit  juice  containing  from  6  to  25 
per  cent,  of  alcohol,  has  present  also  compound  aromatic 
ethers  and  other  volatile  principles. 

Beer  is  a  malt  liquor  containing  3  to  5  per  cent,  alcohol, 
with  bitters  (hops),  and  extractive  (malt). 

Whiskey  is  a  distilled  liquor  containing  30  to  60  per  cent, 
aleohol,  and  also  certain  aromatic  substances. 

The  skeleton  of  a  man  weighs  24  pounds  and  contains 
58  per  cent,  of  calcium  phosphate,  Ca3(PO^)2.  Find  the 
weight  of  phosphorus  present.  (Atomic  weight  of  Ca,  40; 
Of  P,  31.) 

There  are  present  in  the  skeleton  13.92  lbs.  of  calcium 
phosphate  (58  per  cent,  of  24  =  13.92). 

Calcium  phosphate,  molecular  weight  310,  contains  62  of 
phosphorus. 

310  :  ()2  : :  13.!>2  :  X  =  2.784  lbs.  of  phosphorus. 

Distinguish  between  physics  and  chemistry. 

Physics  treats  of  the  phenomena  presented  to  us  by  bodies 
or  masses  of  matter  as  such.  Chemistry  treats  of  the  compo- 
sition of  matter  and  of  the  changes  which  this  composition 
may  undergo. 

What  is  the  unit  of  comparison  in  determining  the  spe- 
cific gravity  of  liquids?    Of  gases? 

For  liquids,  pure  water  at  4°  C,  and  standard  barometric 
pressure  (760  millimetres). 

For  specific  gravity  of  gases  we  use  pure  dry  atmospheric 


80  CHEMISTRY. 

air  at  0°  C.  and  760  millimetres  pressure  or  pure  dry  hydro- 
gen at  the  same  (standard)   temperature  and  pressure. 

Define  qualitative  analysis  and  give  a  principal  method. 

Qualitative  analysis  is  that  form  of  analysis  which  seeks  to 
determine  the  kind  of  substance  present  in  a  compound  or 
mixture. 

A  common  method  is  to  dissolve  the  substance  to  be  ana- 
lyzed and  then  by  means  of  appropriate  reagents  to  precipi- 
tate and  filter  off  successively  its  constituent  parts. 

Define  (a)  element,  (b)  compound,  (c)  mixture,  (d) 
solution,  (e)  precipitate. 

(a)  A  substance  all  of  whose  atoms  are  of  the  same  kind. 
(b)  A  substance  containing  at  least  two  different  kinds  of 
atoms  chemically  combined,  (c)  A  mechanical  mixture  of 
two  or  more  substances,  which  substances  may  be  in  any  pro- 
portion and  retain  their  characteristic  properties,  (d) 
A  solution  is  a  liquid  in  which  a  solid,  or  a  gaseous  substance, 
has  been  disolved.  (e)  A  substance  made  insoluble  in  the 
liquid  in  which  it  was  dissolved,  by  chemical  action. 

Which  of  the  elements  are  gases  at  ordinary  tempera= 
ture  and  pressure? 

Hydrogen,  oxygen,  nitrogen,  chlorine,  fluorine,  argon,  and 
a  number  of  rare  elements. 

Where  do  Na,  Hg,  Cu  occur  in  nature?  Which  occur 
free? 

Copper  occurs  free  in  nature,  and  also  in  a  number  of 
mineral  combinations,  the  sulphide,  carbonate,  oxide,  etc 
Mercu'ry  occurs  free,  although  but  in  limited  quantity. 
Sodium  occurs  principally  in  union  with  chlorine  as  NaCl, 
found  in  sea  water,  mineral  springs,  in  natural  water,  in 
nearly  all  plant  and  animal  structures.  Mercury  is  found 
in  nature  chiefly  in  the  ore  cinnabar,  HgS. 

Describe  hydrochloric  acid  as  to  its  occurrence. 

We  find  hydi-ochloric  acid  present  in  certain  animal  fluids, 


CHEMISTRY.  81 

as  in  gastric  juice,  and  it  is  found  in  a  few  natural  mineral 
waters. 

How  does  each  of  the  following  affect  litmus  paper: 
(a)  H3O,  (b)  H,SO„  (c)  (NH),OH? 

(a)  No  effect,     (b)  Turns  it  red.     (c)  Turns  it  blue. 

The  quantity  of  urine  being  insufficient  for  the  urino= 
meter,  how  would  you  proceed? 

Use  a  small  piknometer,  or  specific  gravity  flask;  weigh  the 
flask  filled  with  urine  and  then  when  filled  with  pure  water. 
Divide  the  w^eight  of  the  urine  by  the  weight  of  water. 

Or,  dilute  the  urine  with  a  measured  quantity  of  water  and 
determine  the  specific  gravity  of  the  dilute  mixture  by  means 
of  the  urinometer.  From  this  calculate  the  true  specific  grav- 
ity, e.  g.,  if  2  parts  of  water  were  added  to  1  part  of  urine, 
and  the  specific  gravity  of  this  mixture  were  1005,  the  true 
specific  gravity  of  the  urine  would  be  1015. 

Distinguish  between  starch  and  sugar.  By  what  histo= 
logic  element  is  starch  converted  into  sugar? 

Starch  is  colloidal,  its  formula,  CgllioOs.  It  is  insoluble 
in  cold  wafer,  forms  a  paste  in  hot  water.  Turns  iodine 
blue,  rotates  light  to  the  right,  has  no  sweet  taste. 

Sugar  is  crystalline,  its  formula,  CiaHaoOn.  It  is  soluble 
in  cold  or  hot  water,  it  rotates  light  to  the  left,  it  yields  no 
color  with  iodine,  it  possesses  a  characteristic  sweet  taste. 
Starch  is  converted  into  sugar  (maltose,  C12H22O11,  and  glu- 
cose, CeHiaOe)  by  ptyalin  and  by  amylopsin. 

Complete  the  equation  CaCl2  +  NajCOg  =. 

CaCl,  +  Na^COg  =  CaCOg  +  2NaCl. 

Mention  the  antidotes  applicable  in  cases  of  poisoning 
from  (a)  oxalic  acid,  (b)  copper  sulphate. 

(a)  Magnesia  and  lime  water. 

(b)  Albumin  and  ferrocyanide  of  potassium. 

What  is  chemical  decomposition? 

Chemical  decomposition  refers  to  the  breaking-up  of  a  <M>m- 
pound  into  simpler  substances. 
6 


82  CHEMISTRY. 

Give  an  example  of  a  synthetic  operation. 

The  formation  of  cupric  oxide  by  heating  the  metal  copper 
in  air  or  oxygen;  or,  mixing  two  parts  hydrogen  and  one 
part  oxygen  by  volume  and  heating,  an  explosion  occurs  and 
vapor  of  water  is  formed. 

What  are  the  products  of  the  combustion  of  ordinary 
coal? 

Principally  carbon  dioxide.  There  may  also  be  produced 
carbon  monoxide,  sulphur  dioxide,  water,  and  other  sub- 
stances resulting  from  the  burning  of  impurities  in  the  coal. 

In  composition  with  what  elements  are  the  following 
most  commonly  found  in  nature:  (a)  Iron,  (b)  gold,  (c) 
silver,  (d)  copper,  (e)  chlorine? 

(a)  Oxygen  or  sulphur,  (b)  Sulphur,  (c)  Sulphur,  tel- 
lurium and  chlorine,     (d)  Sulphur,  oxygen,     (e)  Sodium. 

Describe  the  production  of  oxygen  by  decomposition  of 
potassium  chlorate.     Give  the  formula  and  equation. 

Heat  potassium  chlorate  with  or  without  an  addition  of 
manganese  dioxide  and  oxygen  will  be  liberated. 
2KCIO3  +  heat  =  2KC1  -f  SO^. 

Explain  an  experiment  to  prove  that  chemical  action 
may  be  induced  by  electricity. 

Mix  equal  volumes  of  hydrogen  and  chlorine  gases  in  a 
tube  through  the  sides  of  which  pass  two  platinum  wires 
connected  with  a  battery  or  induction  coil.  An  electric 
charge  being  sent  through  the  wires,  the  hydrogen  and  chlorine 
combine  with  explosive  violence  to  form  hydrochloric  acid. 

Name  and  describe  some  of  the  more  important  potas= 
slum  salts. 

Potassium  carbonate,  KgCOg.  May  be  prepared  from  wood- 
ash  and  from  the  chloride,  a  white  granular,  deliquescent 
powder,  very  soluble  in  water,  insoluble  in  alcohol. 

Potassium  chlorate,  KCIO3.  Colorless,  pearly,  plate-like 
crystals,  soluble  in  16  parts  water,  permanent  in  air,  a  strong 
<»xidizing  agent. 


CHEMISTRY.  83 

Potassium  nitrate,  KNO3.  ^lade  by  the  reaction  between 
sodium  nitrate  and  potassium  chloride.  Prismatic  crystals 
of  cooling,  saline  taste,  slightly  hygroscopic  in  moist  air. 
Soluble  in  3.6  parts  water,  very  sparingly  soluble  in  alcohol. 
A  strong  oxidizing  agent. 

Potassium  bromide,  KBr.  White  cubical  crystals  of  saline 
taste,  soluble  in  1.7  parts  water  and  in  12.5  parts  alcohol. 

Potassium  iodide,  KI.  Similar  to  the  bromide,  soluble  in 
0.7  part  water  and  in  about  12  parts  alcohol. 

Potassium  acetate,  KC2H3O2.  A  white  powder  or  in  crys- 
talline masses  of  a  satin-like  lustre,  odorless  and  having  a 
warming,  saline  taste.  Very  deliquescent,  soluble  in  0.4  part 
water,  and  in  2  parts  alcohol. 

What  is  the  formula  for  (a)  chloroform,  (b)  sulphuric 
ether,  (c)  alcohol? 

(a)  CHCI3.     (b)   (CaHs)^©.     (c)  C2H5OH. 

How  would  you  conduct  an  autopsy  for  the  purpose  of 
testing  for  arsenic  in  the  stomach  and  tissues? 

The  analytical  chemist  should  be  present,  if  possible,  at  the 
autopsy.  Tie  both  pyloric  and  cardiac  ends  of  the  stomach 
and  place  with  its  contents,  in  a  chemically  clean  glass  jar. 
Close  the  jar  with  a  close-fitting  glass  stopper ;  seal  it,  and  im- 
print a  design  upon  the  seal  in  such  manner  that  the  design 
will  be  broken  should  the  jar  be  opened.  Proceed,  in  the 
same  manner,  to  save  a  portion  at  least  of  the  liver,  the  small 
intestine,  portion  of  large  intestine,  the  spleen,  one  kidney, 
the  brain.    Each  of  these  organs  is  to  be  kept  separately. 

Complete  the  following  equations  and  write  the  name 
of  each  resulting  compound  under  its  formula: 
2NaCl  -f  H2S0,= 
CaC03  4-  2HCI  =. 

2NaCl -f  II2SO,  =Na2S0,  -f  2HC1. 

Sudium  sulphate  Hydroi-hldrie  acid. 

CaCO,  -\-  2HC1  =  CaCl^        -f        CO^        4-        H^O. 

C'fllcium  chloride  (  arbon  dioxide  water. 


84  CHEMISTRY. 

How  would  you  determine,  chemically,  whether  a  uri- 
nary  deposit  were  composed  of  urates  or  phosphates? 

Heat  would  dissolve  a  deposit  of  urates,  but  would  not  dis- 
solve phosphates. 

Nitric  acid  would  dissolve  a  deposit  of  phosphates,  but 
would  not  dissolve  urates. 

What  is  dialysis,  and  how  would  you  construct  a  di= 
alyzer? 

Dialysis  is  the  process  of  separating  crystalloids  from  col- 
loids when  both  are  in  the  same  solution. 

It  is  performed  in  a  dialyzer,  which  consists  of  a  glass 
vessel,  the  bottom  of  which  is  formed  of  parchment  or  parch- 
ment paper,  set  in  a  larger  vessel  containing  distilled  water. 
The  mixture  is  placed  in  the  smaller  vessel. 

In  a  short  time  the  crystalloidal  substances  will  have 
passed  through  the  membrane  into  the  distilled  water,  where 
they  may  be  detected,  and  from  which  they  may  be  separated 
by  evaporation.  The  colloidal  material  remains  in  the  dia- 
lyzer, not  being  able  to  pass  through  the  membrane. 

What  is  the  difference  between  the  mercurous  and  mer- 
curie  chloride? 

Mercurous  chloride,  HggCla  or  2HgCl.  A  white  impalpable, 
insoluble  powder,  tasteless,  odorless,  turned  black  by  am- 
monium hydroxide.  Acts  as  a  laxative.  Has  but  slight 
poisonous  action  in  single  dose. 

Mercuric  chloride,  HgCL.  A  white,  crystalline,  soluble  su'b- 
stance,  of  a  sweetish,  burning,  metallic  taste,  giving  a  white 
precipitate  with  ammonium  hydroxide.  Is  very  poisonous ; 
used  externally  as  an  antiseptic,  and  in  concentrated  solutions 
as  a  disinfectant;  internally  as  an  anti-specific,  alterative, 
tonic. 

What  impurities  may  be  present  in  sulphuric  acid,  and 
how  would  you  detect  them? 

Lead.     Appearing  when  strong  sulphuric  acid  is  dilutjeti 


CHEMISTBY.  85 

with  water,  as  a  white  precipitate  or  haziness  of  sulpha^ie  of 
lead. 

Arsenic :  Recognized  by  Marsh 's  test. 

Selenic  acid :  Showing  its  presence  by  communicating  to 
the  acid  the  power  of  dissolving  gold. 

Nitric  acid,  or  oxide  of  nitrogen :  Detected  by  adding  to 
the  suspected  acid  a  mixture  of  strong,  pure  sulphuric  acid 
and  phenol,  and  evaporating  in  a  porcelain  dish  to  dryness, 
when  on  heating  slightly,  should  nitrates  or  nitric  acid  be 
present,  a  pink  coloration  is  observed. 

Organic  matter  in  sulphuric  acid  causes  a  brown  or  black 
coloration. 

What  is  sulphuric  ether,  and  what  is  its  action  upon 
man? 

It  is  the  oxide  of  ethyl  (CoH5)20,  or  ordinary  ether.  It  is 
a  colorless  liquid,  lighter  than  water,  readily  vaporizing  at 
ordinary  temperatures,  its  vapor  being  heavier  than  air  and 
of  a  characteristic  odor.  Ether  produces  in  man,  or  other 
animals  inhaling  its  vapor,  unconsciousness  and  muscular  re- 
laxation, and  may  occasion  death,  through  a  centric  paralysis 
of  respiration. 

How  would  you  detect  the  presence  of  bile  in  the  urine? 

Float  urine  in  test-tube,  over  yellow  nitric  acid;  at  point 
of  contact,  should  bile  be  present,  there  will  appear  a  band 
of  colors,  green,  violet,  and  red. 

Add  cane-sugar  to  urine,  and  warm  a  drop  or  two  of  this 
mixture  on  a  white  porcelain  surface;  add  a  drop  of  strong 
sulphuric  acid,  when,  should  bile  be  present,  there  will  ap- 
pear a  play  of  colors  foraiing  in  concentric  rings,  the  colors 
particularly  prominent  being  yellow,  red  and  green. 

Give  a  reliable  quantitative  test  for  albumin. 

To  a  measured  quantity  of  urine,  add  acetic  acid  to  as- 
sure its  acidity,  boil,  cool  and  filter  through  a  weighed  filter 
paper,  wash  the  coagulated  material  with  water  containing  a 
fe^'  drops  of  acetic  acid,  with  ether,  with  alcohol,  and  again 


86  CHEMISTRY. 

with  boiling  acidified  water.  Then  dry  at  212°  F.,  and  again 
weigh;  deduct  from  this  weight,  weight  of  filter  paper,  and 
from  result  calculate  the  amount  of  albumin.  Clinically 
albumin  is  determined  by  means  of  Esbach's  albumino meter. 

What  is  mucin?     How  would  you  recognize  it  in  urine?  • 

Mucin  is  a  compound  proteid,  occurring  in  the  cement  sub- 
stance of  connective  and  epithelial  tissues;  in  bile  and  in 
secretions  of  mucous  surfaces. 

Test:  It  is  not  precipitated  from  urine  by  boiling,  but  is 
precipitated  on  the  addition  to  urine  of  either  alcohol,  dilute 
mineral  acids,  acetic,  picric  or  citric  acids.  To  detect  it  add 
acetic  acid  to  form  a  layer  below  urine  without  heating,  when 
at  point  of  contact  a  poorly  defined  line  of  precipitate  will 
appear. 

Describe  the  usual  method  of  determining  chemically 
the  presence  of  blood  in  the  urine. 

To  urine  add  a  few  drops  of  tr.  guaiacum  and  then  ozon- 
ized ether ;  the  ether  separates  and  becomes  of  a  fine  sapphire- 
blue  should  blood  be  present. 

Give  a  reliable  quantitative  test  for  sugar  in  the  urine. 

In  each  of  two  bottles  of  about  six  ounces  capacity  place 
four  ounces  of  urine,  adding  to  one  of  the  bottles  a  small  frag- 
ment of  yeast.  Stopper  the  bottles  loosely  and  place  in  a  V 
warm  place,  allowing  them  to  remain  undisturbed  for  from 
12  to  24  hours  and  then  take  the  specific  gravity.  The  dif- 
ference in  specific  gravity  between  the  two  samples,  multi- 
plied by  0.2196,  gives  the  percentage  of  sugar  present. 

What  is  alcohol,  and  how  is  it  formed? 

Alcohol  is  a  compound  of  a  hydrocarbon  radical  with  hy- 
droxyl,  e.  g.,  common  alcohol,  CaH^OH,  formed  by  the  ^r- 
mentation  of  sugar. 

How  is  uric  acid  recognized  chemically? 

Uric  acid  is  recognized  chemically  by  the  murexid  test : 
Evaporate  with  a  few  drops  of  nitric  acid  and  to  the  residue 


CHEMISTRY.  87 

add  a  drop  of  ammonium  hydroxide — a  fine  purple  eolor  is 
obtained. 

Name  the  antidotes  in  a  case  of  stramonium  poisoning. 

Tannic  acid,  strong  infusion  of  coifee,  morphine,  physos- 
tigmine,  pilocarpine. 

What  is  the  principal  pigment  in  normal  urine? 

Urobilin  or  urochrome. 

Give  two  chemical  tests  that  you  would  use  in  water 
supposed  to  be  contaminated  by  sewage. 

(a)  Add  to  the  water  a  drop  or  two  of  dilute  sulphuric 
acid  and  enough  potassium  permanganate  to  give  a  decided 
pink  color,  cover  the  vessel  with  a  glass  plate,  and  if  the  pink 
color  disappears  inside  of  10  minutes  the  water  is  probably 
contaminated. 

(b)  Estimate  the  chlorides  in  the  water,  using  a  standard 
solution  of  silver  nitrate  with  potassium  chromate  as  an  in- 
dicator. If  the  water  contains  an  excessive  quantity  of  chlor- 
ides the  presence  of  sewage  would  be  probable. 

Give  tests  for  the  purity  of  chloroform. 

For  Chlorine:  Drop  the  suspected  chloroform  through  a 
watery  solution  of  potassium  iodide  in  a  test-tube.  Should 
the  chloroform  acquire  a  pink  color,  and  the  supernatant 
liquid  become  yellow  or  brownish  in  tint,  the  presence  of 
free  chlorine  is  indicated. 

For  HCl:  Shake  the  chloroform  with  water,  and  after 
separating  pour  the  water  into  a  clean  tube,  and  rendering 
it  acid  with  a  drop  of  nitric  acid,  add  silver  nitrate  solution; 
should  hydrochloric  acid  or  chloride  be  present  a  white  pre- 
cipitate will  form. 

For  hydrocarbons:  Evaporate  suspected  chloroform  on 
clean  porcelain  surface,  when  no  residue  should  be  left,  nor 
should  there  be  any  foreign  odor. 

For  water:  Add  to  the  chlorofonn  white  anhydrous  copper 
sulphate;  should  the  copper  sulphate  become  blue  in  color  the 
presence  of  water  would  be  indicated. 


88  CHEMISTBY. 

For  acidity :  By  shaking  the  chlorof orm  with  water,  pour- 
ing off  the  water  and  testing  it  with  a  drop  or  two  of  litmus 
solution,  a  red  tint  would  indicate  free  acid. 

Explain  the  process  of  bleaching  with  chlorine. 

Chlorine  bleaches  organic  colors  only  in  the  presence  of 
moisture.  Chlorine  unites  with  the  hydrogen  of  moisture, 
setting  the  oxygen  free.  In  bleaching  with  chlorine  we  make 
use  of  a  mixture  of  chlorinated  lime  and  water.  The  fabric 
to  be  bleached  is  first  "  soured  "-by  passing  through  a  dilute 
acid  solution.  It  is  then  placed  in  the  bleaching  mixture  and 
afterward  thoroughly  washed  with  proper  reagents  to  remove 
any  excess  of  acid,  chlorine  or  lime. 

State  the  most  common  and  convenient  antidotes  for 
poisoning  by  mineral  acids.  State  also  the  course  to  be 
pursued  when  the  poison  to  be  antidoted  is  unknown. 

Convenient  antidotes  for  poisoning  by  mineral  acids  are: 
Calcined  magnesia,  and  alkaline  carbonates,  as  baking  soda, 
chalk,  and  soap.    Then  use  oils,  fats,  milk,  flour,  eggs. 

If  poison  be  of  unknown  character  administer  an  emetic, 
as  mustard  and  water,  or  use  stomach  pump  or  syphon  tube. 
If  reason  to  suspect  poison  to  be  of  alkaloidal  nature,  gi^e 
tannic  acid  or  permanganate  of  potassium.  Milk  with  white 
of  egg  is  a  generally  useful  antidote  for  irritant  poisons. 

Use  ammonia,  whiskey  or  strong  coffee  as  stimulants,  and 
meet  symptoms  as  they  arise. 

How  would  you  make  Fehling's  solution? 

Prepare  in  2  parts.  I.  34.639  grammes  pure  crystallized 
copper  sulphate  dissolved  in  water  and  diluted  to  500  Cc. 
II.  173  grammes  Eochelle  salt  and  60  grammes  sodium  hy- 
droxide, dissolved  in  water  and  diluted  to  500  Cc.  For  use 
mix  equal  volumes  of  I.  and  II.  Ten  Cc,  of  the  mixed  solu- 
tion will  be  reduced  by  0.05  gramme  of  glucose. 

What  element  composes  over  half  the  matter  of  the 
earth? 

Oxygen. 


CHEMISTBY.  89 

What  is  oxidation? 

Chemical  union  with  oxygen. 

What  is  ozone? 

An  allotropic  form  of  oxygen,  each  molecule  consisting  of 
three  atoms  of  oxygen. 

What  is  Paris  green? 

A  double  salt  of  copper  metarsenite  and  copper  acetate. 

Cu(C2H302)2.3Cu(As02),. 

What  is  the  chemical  name  of  Rochelle  salts? 

Potassium  sodium  tartrate,  KNaC^H^Og. 

What  is  the  chemical  designation  of  the  ordinary  alco- 
hol of  commerce? 

Ethyl  alcohol. 

From  what  substances  is  ether  obtained? 

Ether  results  from  distilling  together  sulphuric  acid  and 
ethyl  alcohol. 

Name  the  various  states  in  which  matter  may  exist. 

Solid,  liquid,  gaseous,  and  Crookes  or  radiant  state. 

What  is  the  difference  between  atomic  weight  and  spe- 
cific gravity? 

Atomic  weight  is  the  relative  weight  of  one  atom  of  a  sub- 
Ktance  as  compared  with  the  weight  of  an  atom  or  some  other 
substance  taken  as  a  standard.  Specific  gravity  is  the  relative 
weight  of  one  volume  of  a  substance  as  compared  with  the 
weight  of  an  equal  volume  of  some  other  substance  t-aken  as  a 
standard. 

Name  and  describe  a  deliquescent  salt. 

Potassium  carbonate,  KjCOs.  a  white  granular  powder, 
<Kiorless  and  having  a  Sftrong  alkaline  taste,  very  deliques- 
cent and  verv  soluble  in  water,  insoluble  in  ak'<>hol. 


90  CHEMTSTRY. 

Complete  the  following  equations: 
(a)  2NH,CI  4-  Ca(0H)2  = 
(b)2KN03  +  H2S0^=. 

(a)  2NH4CI  +  Ca(0H)2  =  CaCl^  +  2NH3  +  2H2O. 

(b)  2KNO3  4-  H2SO,  =  K2SO4  +  2HNO3. 

Explain  the  reaction  which  occurs  when  the  solution  of 
the  two  parts  of  a  seidlitz  powder  are  mixed. 

Seidlitz  powder  consists  of  Rochelle  salts,  120  grains;  sod- 
ium bi-earbonate,  40  grains;  these  are  wrapped  in  the  blue 
paper. 

In  the  white  paper  is  placed  35  grains  of  tartaric  acid. 

H^C^H.Os  +  2NaHC03  =  NaoC^H.Oe  +  SH^O  +  SCO^. 

To  what  salts  do  most  cathartic  mineral  waters  owe 
their  virtues? 

To  magnesium  sulphate,  or  to  sodium  sulphate. 

Explain  the  construction  of  the  safety  lamp  used  by 
miners,  and   state  the  principle  involved. 

The  flame  of  the  lamp  is  surrounded  by  a  fine  wire  gauze, 
the  mesh  of  which  is  very  small.  Each  individual  mesh  eon- 
tains  its  film  of  air,  and  as  air  is  a  poor  conductor  of  heat, 
the  transmitted  heat  of  the  flame  is  decreased  below  the 
ignition  point. 

What  is  pepsin? 

A  proteolytic  ferment  or  enzyme  obtained  from  the  glandu- 
lar layer  of  the  fresh  stomach  of  the  hog — the  principal  fer- 
ment of  gastric  juice.  A  yellowish  or  greyish-white  powder, 
soluble  in  water  and  glycerin,  but  insoluble  in  alcohol. 

Mention  the  antidote  applicable  in  case  of  poisoning 
from  silver  nitrate. 

Common  salt,  NaCl. 

What  is  a  chemical  symbol? 

An  abbreviation  for  the  name  of  an  element. 


CHEMISTRY.  91 

What  is  the  chemical  composition  of  ordinary  alum? 

Alum  is  a  double  sulphate  of  aluminum  and  potassium. 
Its  formula  is  Al2(SOj3K2SO,.24H20,  or  (U.  S.  P.), 
AIKCSOJJSH^O. 

Write  the  formula  of  (a)  common  salt,  (b)  nitric  acid, 
(c)  sulphuric  acid,  (d)  hydrochloric  acid,  (e)  carbonic  an  = 
hydride. 

(a)   NaCl;   (b)   HNO3 ;   (c)  H^SO,;   (d)  HCl;  (e)   CO^. 

What  is  the  simplest  test  of  the  presence  of  (a)  an 
acid,  (b)  iodine? 

(a)  Turns  litmus  paper  red;  (b)  turns  starch  mucilage 
bluish-black. 

Complete  the  following  reactions: 
CaCI,  +  Na^COs  = 
(C,H,)H0  +  C3H,HS0,=^ 

CaCl2  +  Na^COg  =  CaCOs  +  2NaCl. 
(CHJHO  -h  C3H,HS0,=  (C2H,),0  +  H^SO,. 

Mention  a  test  for  ozone.  Explain  how  ozone  may  be 
prepared  in  the  laboratory,  and  compare  its  properties 
with  those  of  oxygen. 

Gives  a  dark  blue  color  to  paper  that  has  been  wet  with 
iodide  of  potassium  and  starch  mucilage.  Ozone  is  prepared 
by  subjecting  air  or  oxygen  to  silent  electric  discharges,  as 
in  the  "  Siemens  "  induction  tube,  or  by  the  slow  oxidation  of 
moist  phosphorus. 

Its  properties  are  similar  to  those  of  oxygen,  save  that  it 
acts  more  vigorously  as  an  oxidizing  agent  and  in  concen- 
trated form  is  irrespirable. 

Name  four  elements  that  enter  into  the  formation  of 
organic  bodies. 

Carbon,  hydrogen,  oxygen,  nitrogen. 

What  preparation  of  gun  cotton  is  used  in  medicine, 
and  what  is  its  solvent? 

Pyroxylin.  Soluble  in  25  parts  of  a  mixture  of  3  volumeH 
of  ether  and  I  volume  of  alcohol. 


92  CHEMI8TBT. 

How  may  uric  acid  be  obtained  from  urine? 

By  adding  to  the  urine  strong  hydrocliloric  aoid,  when 
after  the  mixture  has  stood  from  12  to  24  houre  uric  acid 
will  appear  in  minute  crystals. 

Mention  the  antidotes  applicable  in  cases  of  poisoning 
from  zinc  chloride. 

Albumin,  white  of  egg  in  milk,  magnesia  in  milk,  tannin. 

Mention  the  elements  that,  under  ordinary  circum= 
stances,  exist  as  (a)  liquids,  (b)  gases. 

(a)  Bromine  and  mercury,  (b)  Oxygen,  hydrogen,  nitro- 
gen, chlorine,  fluorine,  argon. 

Give  the  preparation,  formula,  properties  and  uses  of 
potassium  cyanide. 

Potassium  cyanide,  KCN.  Prepared  by  saturating  potas- 
sium hydroxide  with  hydrocyanic  acid.  A  white  amorphous 
deliquescent  salt,  easily  fusible,  and  smelling  of  cyanogen. 
Very  soluble  in  water,  highly  poisonous,  used  in  electro- 
plating, in  metallurgy,  and  medicinally,  as  a  cardiac  seda- 
tive, as  a  sedative  addition  to  cough  mixtures,  in  gastralgia, 
reflex  headaches,  nervous  vomiting,  etc. 

Define  valence,  radical.     Illustrate. 

By  valence  we  refer  to  that  property  by  virtue  of  which 
an  element  or  radical  will  hold  in  combination  a  certain 
number  of  atoms  of  aSiother  kind.  Thus  oxygen  has  a  val- 
ence of  two,  as  shown  in  water,  HgO. 

A  radical  is  an  atom  or  group  of  atoms  incapable  of  exist- 
ing in  an  uncombined  state.     E.  g.    (SO4),   a  radical  with 
valence  of  II.  occurring  in  sulphuric  acid,   H2SO4,   and  in  ■ 
sulphates. 

What  is  the  formula  of  carbolic  acid? 

CeH.OH. 

How  may  phosphorus  be  obtained?  Describe  the  allo- 
tropic  forms  of  phosphorus. 

To  bone-'ash  add  sulphuric  acid  and  water ;  and  after  stand- 


CHEMISTRY.  93 

ing  24  hours  decant  the  liquid,  evaporate  it  to  dryness  and 
heat  the  residue  strongly;  to  this  result  add  sand  and  char- 
coal and  distil,  receiving  the  resultant  phosphorus  vapor 
under  water,  where  it  solidifies. 

Ordinary  phosphorus  is  a  translucent  wax-like  solid,  lumin- 
ous in  the  dark,  poisonous,  insoluble  in  water,  slightly  soluble 
in  alcohol,  soluble  in  oils  and  in  carbon  disulphide.  Red  or 
amorphous  phosphorus  is  a  reddish-brown  amorphous  powder, 
not  luminous  in  the  dark,  not  poisonous,  insoluble  in  oils  and 
in  carbon  disulphide.  There  is  also  a  "  metallic  "  form  of 
phosphorus  occurring  in  black,  needle-like  crystals. 

Give  the  formula  and  chemical  name  of  each  of  the 
following  substances,  indicating  those  soluble  in  water; 
Nitre,  Epsom  salts,  lunar  caustic,  aqua  fortis,  Paris  green, 
gypsum. 

Nitre,  potassium  nitrate,  KNO3,  soluble.  Epsom  salts,  mag- 
nesium sulphate,  MgS04,  soluble.  Lunar  caustic,  silver  ni- 
trate, AgNOg,  soluble.  Aqua  fortis,  nitric  acid,  HNO3,  soluble. 
Paris  green,  cupric  acetometarsenite,  Cu(  0311302)2 :3Cu- 
(As02)2j  insoluble.  Gypsum,  calcium  sulphate,  CaS042H20, 
insoluble. 

What  is  the  chemical  designation  of  nitroglycerin? 
How  is  nitroglycerin  manufactured? 

Glyceryl  trinitrate,  Cgllc (NOg)^.  Nitroglycerin  is  made 
by  cautiously  adding  glycerin  to  a  mixture  of  strong  nitric 
and  sulphuric  acids. 

What  are  amins?     Give  an  example. 

They  are  substances  which  result  when  the  hydrogen  of 
ammonia  is  replaced  by  hydrocarbon  radicals. 

Example:  When  NH3  has  one  hydrogen  atom  replaced  by 
CzHn  it  forms  NHjCjHb,  ethyl  amin. 

Define  porosity,  capillary  attraction. 

Porosity  refers  to  that  essential  property  of  matt<M-  by 
virtue  of  which  spaces  called  pores  exist  between  the  mole- 
cules of  all  substances.     Capillary  attraction  is  the  exhibi- 


94  CHEMISTRY. 

tion  of  the  property  of  adhesion,  between  the  molecules  of  a 
liquid  and  the  material  of  a  tube,  rod  or  surface  wetted  by 
it,  shown  most  characteristically  in  the  rise  of  liquids  in 
small  (capillary)  tubes. 

How  do  chemical  antidotes  and  physiologic  antidotes 
differ  in  action?     Illustrate. 

A  chemical  antidote  forms  an  insoluble  or  harmless  sub- 
stance by  combining  chemically  with  the  poisonous  substance ; 
thus  magnesium  sulphate  is  antidotal  to  soluble  salts  of  lead, 
as  it  combines  chemically  with  lead  to  form  the  insoluble 
sulphate.  A  physiologic  antidote  acts,  not  directly  upon  the 
poisonous  body,  but  by  producing  a  physiologic  action  op- 
posed to  that  which  the  poison  occasions;  thus  we  use  atro- 
pine as  the  physiologic  antidote  to  morphine. 

Mention  two  elements  of  each  of  the  following  groups: 
Univalent,  bivalent,  trivalent,  quadrivalent. 

Univalent :  Hydrogen  and  chlorine. 
Bivalent:  Oxygen  and  magnesium. 
Trivalent:  Arsenicum  and  boron. 
Quadrivalent:  Silicon  and  platinum. 

What  is  the  difference  between  analytic  methods  and 
synthetic  methods  in  chemistry? 

Analytical  methods  seek  to  break  down  compounds  into 
simpler  bodies. 

Synthetic  methods  seek  to  build  up  compound  bodies  by 
the  union  of  simpler  ones. 

What  gases  are  usually  generated  during  the  process  of 
destructive  distillation? 

If  the  destructive  distillation  be  of  soft  coal,  we  find  among 
the  gases  resulting  hydrogen,  marsh  gas,  olefiant  gas,  acety- 
lene gas,  ammonia,  sulphuretted  hydrogen,  carbon  monoxide 
and  carbon  dioxide. 

Describe  sulphur,  and  mention  its  important  compounds. 

Sulphur:  symbol  S,  atomic  weight,  32  (31.83),  valence  II., 


CHEMISTRY.  95 

IV.,  found  free,  in  volcanic  regions,  and  in  combination  in 
form  of  sulphates  and  sulphides.  It  is  a  lemon-yellow  solid 
element.  No  taste  or  odor.  It  is  strongly  electro-negative, 
is  non-metallic,  resembles  oxygen  in  its  chemical  combinations. 
It  is  insoluble  in  water,  slightly  soluble  in  hot  alcohol,  freely 
soluble  in  carbon  disulphide. 

Important  compounds  are,  sulphur  dioxide,  sulphurous 
acid,  sulphuric  acid,  sulphur  iodide,  and  hydrosulphuric  acid. 
Combined  with  metals  we  have  many  important  sulphates, 
sulphites,  and  sulphides. 

What  is  boron?  Give  its  principal  compounds.  What 
is  the  chemical  importance  of  boron  in  medicine? 

Boron:  symbol  B,  atomic  weight,  11  (10.9),  valence  III.,  is 
a  rare,  solid,  non-metallic  element,  important  because  of  its 
principal  compounds,  boric  acid,  H3BO3,  and  borax  or  sodium 
borate,  Na^B^Oj,  both  of  which  are  antiseptic,  mildly  astrin- 
gent and  detergent. 

Describe  the  incandescent  electric  light,  and  explain  its 
use  as  an  aid  to  diagnosis  in  medical  and  surgical  practice. 

The  incandescent  electric  light  consists  of  a  thin  glass  bulb 
exhausted  of  air  and  containing  a  filament  of  carbon  or 
platinum  wire  coiled  in  semicircle  or  other  design.  On  passing 
a  current  of  electricity  this  filament,  because  of  the  resistance 
it  offers,  becomes  incandescent,  thus  ^ving  liirht. 

The  incandescent  electric  light  has  considerable  value  in 
medicine  and  surgery  for  illuminating  passages  which  can- 
not be  directly  lighted;  thus  we  use  it  in  the  examination  of 
larynx;  in  the  form  of  the  cystoscope,  in  the  bladder.  It  is 
used  also  to  illuminate  the  interior  of  the  stomach,  thus 
facilitating  the  examination  of  this  organ. 

Give  the  composition  and  properties  of  chloroform. 

Chloroform,  CIICl.,,  is  a  colorless,  heavy,  volatile  liquid, 
with  specific  gravity  about  1.5  and  a  characteristic  sweet- 
ish odor.  It  is  soluble  in  200  parts  water  and  freely  soluble 
in  alcohol,  ether,  and  oils.  Used  for  producing  general  anes- 
thesia, and  as  a  solvent. 


96  CHEMISTRY. 

Complete  the  following  equation  and  give  the  resulting 
compounds: 

2C2H3KO2  +  H2SO4  = 

2C2H3KO2  +  H2SO,  =  K2SO,       +       2HC2H3O,. 
Potassium  sulphate.  Acetic  acid. 

What  organic  acids  are  present  in  vegetables  and  fruits? 

Citric  acid,  malic  acid,  tartaric  acid,  oxalic  acid,  gallic 
acid,  tannic  acid,  etc. 

Describe  and  illustrate  the  distinction  between  organic 
and  inorganic  compounds. 

Inorganic  compounds  occur  in  the  mineral  kingdom,  and 
may  contain  any  of  the  elementary  forms  of  matter;  the 
number  of  atoms  in  the  molecule  of  inorganic  compounds  is 
usually  small.  Example :  Sodium  chloride,  magnesium  sul- 
phate. 

Organic  compounds  all  contain  carbon,  combined  with  one 
or  more  of  the  following — ^oxygen,  hydrogen,  nitrogen,  sul- 
phur and  phosphorus — there  are  frequently  many  atoms  pres- 
ent and  the  molecules  are  often  complex.  Examples :  Starch, 
albumin. 

Give  the  chemical  composition  of  (a)  Glauber's  salt, 
(b)  Epsom  salt. 

(a)  Sodium  sulphate,  NaoSO^.  (b)  Magnesium  sulphate, 
MgSO,. 

Into  what  two  principal  groups  are  elements  divided? 
Mention  five  elements  that  exist  uncombined  in  nature. 

Into  the  electro-positive  metals  and  the  electro-negative 
non-metals.     Oxygen,  nitrogen,  sulphur,  gold,  silver. 

Mention  the  acid  constituents  of  bile. 

Taurocholic  and  glycocholic  acids. 

What  is  hemoglobin?    On  what  does  its  color  depend? 

It  is  the  organic  coloring  principle  of  red  blood  corpuscles, 
a  compound  of  the  iron-holding  substance  hematin  and  the 
proteid  substance  globin. 


CHEMISTRY.  97 

Its  color  depends  upon  its  degree  of  oxidation,  oxyhemo- 
globin in  mass  giving  a  scarlet,  hemoglobin,  a  bluish  red. 

Differentiate  nitrates  and  nitrites.  Mention  two  com= 
pounds  of  each  group  commonly  used  in  medicine. 

Nitrates  are  salts  of  nitric  acid  and  contain  the  radical 
NO3.  Nitrites  are  salts  of  nitrous  acid  and  contain  the 
radical  NO2.  Examples:  Potassium  nitrate,  KNO3,  lead  ni- 
trate PbNO.,.     Sodium  nitrite,  NaNO,,  amyl  nitrite,  C5H11NO2. 

What  reaction  takes  place  when  chloral  hydrate  is  mixed 
with  an  alkali?     Illustrate. 

There  results  chloroform,  a  metallic  formate  and  water. 
CClgCOH.H.O  +  KOH  =  CHCI3  -f  KCOOH  +  H^O. 

What  salt  of  mercury  is  soluble  in  water?  Give  the 
name  and  formula  of  a  salt  of  silver  used  in  medicine. 

Mercuric  chloride,  IlgCla-    Silver  nitrate,  AgNOa. 

Describe  the  test  for  detecting  the  presence  of  strych- 
nine. 

Dissolve  a  crystal  of  the  alkaloid  in  a  drop  of  strong  sul- 
phuric acid  on  a  watch-glass,  and  drag  through  the  solution 
by  means  of  a  glass  rod  a  fragment  of  potassium  dichromate : 
a  play  of  colors  will  be  produced — dark  violet-blue,  purple, 
cherry- red,  and  reddish-yellow. 

What  is  a  hydrocarbon? 

A  hydrocarbon  is  an  oi'ganic  compound,  the  molecule  of 
which  consists  of  carbon  and  hydrogen  atoms  only. 

What  is  the  faradic  current?     How  is  it  produced? 

The  faradic  current  is  an  induced  current  of  electricity 
obtained  by  use  of  an  induction  coil.  An  induction  coil  is 
constructed  as  follows:  A  small  coil  of  large  diameter  wire 
is  surrounded  by  a  coil  of  longer  and  much  thinner  wire. 
An  interrupted  current  of  electricity  from  a  battery  is  sent 
through  the  inner  (primary)  coil — with  each  "  make  "  and 
7 


98  CHEMISTRY. 

' '  break  ' '  of  this  primary  current  a  secondary  current  is  in- 
duced in  the  outer  (secondary)  coil.  This  secondary,  in- 
duced, interrupted  current  is  the  Faradic  cun-ent. 

What  is  synthesis?  Mention  three  coaI=tar  products 
extensively  used  in  medicine  that  are  prepared  in  the 
chemical  laboratory  by  synthesis. 

Synthesis  is  the  act  of  constructing  a  compound  body  from 
its  component  parts.  Synthetical  compounds  used  in  medi- 
cine obtained  from  coal  tar  include  salicylic  acid,  phenace- 
tine,  saccharin. 

Differentiate  a  mass  of  matter,  a  chemical  compound 
and  an  elementary  body. 

An  elementary  body  is  a  substance  that  cannot  be  reduced 
to  any  simpler  form,  that  is,  it  contains  but  one  kind  of 
atom.  A  chemical  compound  is  the  result  of  the  chemical 
union  of  two  or  more  elementary  bodies.  A  mass  of  matter 
is  an  aggregation  of  either  elementary  or  compound  molecules. 

Explain  the  following  terms:  Chemical  reaction,  alka> 
line  reaction. 

Chemical  reaction  refers  to  the  interchange  of  atoms  or 
radicals  which  occurs  during  a  chemical  change.  A  substance 
is  said  to  have  an  alkaline  reaction  when  it  changes  red  litmus 
to  blue. 

Describe  some  method  for  (a)  analysis  of  water,  (b)  the 
synthesis  of  water. 

(a)  Pass  water  in  the  form  of  steam  through  an  iron  pipe 
heated  to  redness — ^the  oxygen  will  enter  into  chemical  union 
with  the  iron,  forming  magnetic  oxide  of  iron,  Fe304,  and 
hydrogen  will  issue  from  the  distal  end  of  the  pipe. 

(b)  Pass  dry  hydrogen  over  copper  oxide  placed  in  a  hard 
glass  tube  and  heated  to  redness — the  hydrogen  will  enter 
into  chemical  combination  with  the  oxygen,  and  vapor  of 
water  will  issue  from  the  distal  end  of  the  tube. 


CHEMISTRY.  99 

State  the  chemical  properties  of  carbon.  Describe  two 
allotropic  forms  of  carbon. 

Carbon:  symbol  C,  atomic  weight,  12  (11,91),  valence  II., 
IV.,  an  electro-negative  solid  element.  It  resists  the  action  of 
most  reagents  but,  at  high  temperatures,  combines  readily 
with  oxygen  to  form  two  oxides,  carbon  monoxide  and  carbon 
dioxide.  Combines  with  hydrogen  to  form  many  bodies 
known  in  organic  chemistry  as  hydrocarbons.  It  forms  bin- 
ary combinations  with  most  non-metals  and  with  a  few  metals. 
It  is  non-poisonous. 

An  allotropic  form  of  carbon  is  graphite ;  an  opaque,  grey- 
ish-black substance  crystallizing  in  hexagonal  plates  used  as 
a  lubricant,  for  making  crucibles,  lead  pencils,  etc.  Diamond, 
another  allotropic  form  of  carbon,  occurs  in  transparent  octa- 
hedral crystals,  of  high  refracting  power,  is  the  hardest  sub- 
stance known,  and  is  insoluble  in  all  liquids. 

Mention  the  principal  constituents  of  muscle. 

Water  about  75  per  cent,  and  solids  about  55  per  cent. 
The  characteristic  solid  is  myosinogen  belonging  to  the  class 
of  globulins.  Other  substances  are  creatine,  creatinine,  gly- 
cogen, gluco.se,  lactic  acid,  sarcine,  adenine,  etc.  The  chief 
mineral  constituent  present  is  potassium  phosphate. 

How  is  the  air  of  an  apartment  tested  to  determine  the 
presence  and  amount  of  carbon  dioxide  in  it? 

A  measured  volume  of  air  is  drawn  through  two  weighed 
tubes;  the  first,  containing  calcium  chloride,  absorbs  the 
moisture,  the  second,  containing  potassium  hydroxide,  absorbs 
the  carbon  dioxide.  By  the  increase  in  weight  of  the  second 
tube  the  amount  of  carbon  dioxide  in  the  air  may  be  deter- 
mined. 

Give  names  and  formulas  of  the  salts  of  iron  commonly 
used  in  medicine. 

Ferrous  carbonate,  FeCOg;  ferrous  iodide,  Felo-,  ferrous 
sulphate,  FeSO^:  ferrous  lactate,  Fe(C8H503)2.  Ferric 
eliloride.    Fe.Cle;    ferric   hydroxide,    FeoCOHle;    ferric   sul- 


lUO  CHEMISTRY. 

phate,  Fe2(S0j3;  ferric  alum,  Fe2(SOj3(NHj2S04.24H20; 
ferric  nitrate,  Fe2(N03)o;  ferric  phosphate,  Fe2(P04)2;  ferric 
pyrophosphate,  Fe4(P207)3.  There  are.  also,  the  so-called 
scale  compounds,  salts  of  iron,  of  iron  and  ammonium,  of 
iron  and  potassium  and  of  iron,  quinine  and  strychnine,  with 
citric  and  tartaric  acids. 

Mention  two  salts  of  mercury  commonly  used  in  medi= 
cine.    Give  their  formulas. 

Mercuric  chloride,  HgClj. 

Mercurous  chloride,  HgoClg,  or  2HgCl. 

What  conditions  favor  putrefaction?  What  conditions 
may  prevent  putrefaction  in  dead  organisms? 

Presence  of  moisture,  warmth,  and  bacteria.  Putrefaction 
may  be  prevented  by  the  exclusion  of  bacteria,  by  exclusion 
of  moisture,  by  the  preservation  of  low  temperatures,  and  by 
the  use  of  germicides. 

Give  source,  character  and  uses  of  atropine.  Describe 
the  symptoms  of  poisoning  by  atropine. 

Atropine  is  an  alkaloid  obtained  from  belladonna.  A  white, 
crj^stalline  powder  soluble  in  450  parts  of  water  and  in  1.46 
parts  of  alcohol.  Used  as  a  mydriatic,  antispasmodic,  and 
stimulant.  Typical  symptoms  produced  are  dilatation  of 
pupil  of  eye,  dryness  of  throat,  flushing  of  face,  talkative 
delirium;  later  paralysis  of  centric  origin.  Pulse  ait  first 
slow,  hard :  later  soft  and  dicrotic,  rapid. 

Give  the  properties  of  common  alum. 

It  is  a  white,  odorless  crystalline  substance  of  a  sweetish, 
strongly  astringent  taste,  a  mechanical  emetic.  It  is  soluble 
in  cold  water,  more  soluble  in  hot  water,  insoluble  in  alcohol. 

Heated,  it  loses  its  water  of  crystallization,  forming  the  so- 
called  exsiccated  alum. 

What  metallic  chemical  elements  are  found  in  the  body 
in  various  combinations? 

Iron,  magnesium  calcium,  potassium  and  sodium. 


CHEMISTRY.  lOl 

Differentiate  hydracids  and  oxyacids. 

A  hydracid  is  an  acid  containing  no  oxygen.  An  oxyacid 
is  an  acid  containing  oxygen. 

Give  the  chemistry  of  lithium. 

Lithium,  symbol  Li,  atomic  weight,  7  (6.98),  valence  I., 
occurs  in  nature  as  the  chloride,  carbonate,  and  phosphate. 
A  soft  silvery-white  metal,  sp.  gr.  0.589,  oxidizes  on  ex- 
posure to  air,  decomposes  water,  setting  the  hydrogen  free. 
A  member  of  the  alkali  group  of  metals. 

What  is  the  principal  source  of  urea  in  the  human 
economy? 

Urea  is  the  result  of  the  oxida;tion  of  nitrogenous  tissues; 
it  is  the  end  product  of  normal  nitrogenous  metabolism. 

Give  the  formula  of  ammonium  chloride.  Describe  the 
method  of  preparing  ammonium  chloride. 

Ammonium  chloride,  NII^Cl.  It  is  prepared  by  saturating 
ammonium  hydroxide  with  hydrochloric  acid,  and  evaporat- 
ing the  solution. 

Give  the  chemical  name  and  properties  of  (a)  cream  of 
tartar,  (b)  plaster  of  Paris. 

(a)  Potassium-hydrogen  tartrate  or  potassium  bitartrate. 
KIIC^H^Oo,  occurs  in  colorless  crystals  or  as  a  white  powder 
permanent  in  air,  soluble  in  200  parts  water;  very  sparingly 
soluble  in  alcohol. 

Calcium  sulphate,  CaS04,  a  fine  white,  odorless  and  taste- 
less powder,  nearly  insoluble  in  water.  Mixed  with  one-half 
its  weight  of  water  it  fomis  a  paste  which  hardens  to  a  firm 
plaster. 

Give  the  physical  and  chemical  properties  of  hydro- 
chloric acid.     How  is  hydrochloric  acid  prepared? 

Hydrochloric  acid,  HCl,  is  a  colorless  gas,  soluble  in  water. 
In  this  form,  when  pure,  is  occurs  as  a  colorless  liquid,  fum- 
ing in  air,  with  caustic  and  corrosive  action  upon  organic 
tissue.     Specific  gravity  is  about  1.2. 


102  CHEMISTRY. 

It  is  a  monobasic  hydracid,  and  in  union  with  bases  forms 
salts  called  chlorides  nearly  all  of  which  are  soluble  in  water 

Hydrochloric  acid  may  be  prepared  by  heating  sodium 
chloride  with  sulphuric  acid. 

Describe  Fehling's  test  for  sugar  in  urine. 

Fehling's  test:  Dilute  the  Fehling's  solution  with  three 
volumes  of  water,  heat  to  boiling — the  solution  should  re- 
main clear — ^and  then,  to  the  hot  solution,  add  the  'urine 
drop  by  drop.  A  yellowish-red  precipitate  of  cuprous  hy- 
droxide and  oxide  indicates  the  presence  of  glucose. 

Complete  the  following  reaction: 
PCl3  +  3H20  = 

PCI3  +  3H2O  =  H3PO3  -f  3HC1. 
How  are  the  phosphates  produced  in  the  animal  body? 

The  phosphates  exist  ready  formed  in  plant  foods,  as  in 
wheat.  They  are  also  present  in  the  animal  tissues  that 
are  used  for  food. 

Give  the  symbol,  atomic  weight  and  the  occurrence  in 
nature  of  bismuth. 

Symbol,  Bi.  Atomic  weight,  207  (206.9).  Occurs  native 
and  as  the  sulphide,  frequently  associated  with  arsenic. 

Give  the  formulas  of  the  nitrogen  acids.  How  is  nitro= 
gen  prepared  in  the  laboratory? 

Hyponitrous  acid,  UNO.  Nitrous  acid,  HNOg.  Nitric  acid, 
HNO3. 

Nitrogen  is  prepared  by  burning  phosphorus  in  a  confined 
space  until  the  oxygen  is  all  removed,  or,  by  heating  ammon- 
ium nitrite.    NH^NOg  +  heat  =  N.  +  2H2O. 

Give  chemical  name  of  (a)  common  table  salt,  (b)  soot, 

(c)  vinegar,  (d)  verdigris. 

(a)  Sodium  chloride,     (b)  Carbon,     (c)  Dilute  acetic  acid. 

(d)  Basic  cupric  acetate. 

What   reaction   of   urine   favors   the   deposition   of   uric 


CHEMISTRY.  103 

acid  gravel  or  calculi?     What  is  the  reaction  of  the  urine 
during  the  formation  of  a  phosphatic  calculus? 

(a)  A  strongly  acid  reaction,     (b)  An  alkaline  reaction. 

What  is  nitroglycerin?  Give  the  medical  properties  of 
nitroglycerin. 

Nitroglycerin  is,  chemically,  glyceryl  trinitrate  C3H5- 
(N03)3.  Made  by  the  action  of  nitric  acid  on  glycerin,  in 
the  presence  of  strong  sulphuric  acid — is  glycerin  in  which 
three  Oil  radicals  have  been  replaced  by  three  NO3  radicals. 

It  is  used  medicinally  in  a  one  per  cent,  alcoholic  solution, 
as  a  vasodilator,  to  relieve  heart  tension  by  lowering  the  blood 
pressure.^ 

What  is  (a)  starch,  (b)  dextrin? 

(a)  Starch,  CJl^o^^,  is  a  white  odorless,  tasteless  carbo- 
hydrate, insoluble  in  ether,  alcohol,  or  cold  water,  forming 
a  colloidal  mucilaginous  mass  in  hot  water.  Found  in  all 
plants,  most  abundantly  in  tlie  root,  soft  parts,  and  seeds. 

(b)  Dextrin,  CeHjoOj,  isomeric  with  starch,  may  be  pro- 
duced from  it  by  the  action  of  dry  heat,  by  the  action  of 
ferments,  and  by  the  action  of  dilute  acids.  An  amorphous 
substance  insoluble  in  ether  or  alcohol  but  soluble  in  cold 
wat€r. 

Describe  and  state  the  uses  of  the  thermometer,  the 
barometer  and  the  hygrometer. 

A  thermometer  is  a  capillary  tube  containing  mercury 
hermetically  sealed,  with  a  bulb  at  the  lower  end  and  a  gradu- 
ated stem  above.  It  is  used  to  determine  the  degree  of  tem- 
perature by  the  expansion  of  the  mercury  in  the  tube. 

A  barometer  is  an  instrument  for  measuring  atmospheric 
pressure.  Fill  a  long  gla.ss  tube,  sealed  at  one  end,  with 
mercury  and  invert  it  in  a  cup  of  mercury.  The  mereury 
in  the  tube  will  fall  until  its  weight  is  just  balanced  by  the 
atmospheric  pressure.  Ordinarily  the  height  of  the  mer- 
cury column  will  be  about  30  inches.     As  the  atmosphfric 


104  CHEMISTRY. 

pressure  lessens,  the  mercury  falls,  as  the  atmospheric  pres- 
sure becomes  greater,  the  mercury  rises. 

A  hygrometer  is  used  to  determine  the  degree  of  humidity 
of  the  atmosphere.  The  most  usual  form  of  instrument  is 
that  known  as  the  ' '  Dry  and  Wet  Bulb  ' ' — ^two  thermometers, 
side  by  side,  the  bulb  of  one  exposed  to  the  air,  the  bulb  of 
the  other  kept  constantly  wet  by  threads  of  cotton  dipping 
in  a  compartment  containing  water.  The  drier  the  air  the 
greater  the  difference  in  temperature  reading  between  the  two 
instruments.  Tables  have  been  prepared  by  which  the  exact 
humidity  of  the  atmosphere  may  be  determined. 

Explain  the  method  of  producing  X  or  Roentgen  rays. 

The  X  or  Roentgen  rays  are  produced  by  passing  a  current 
of  electricity  of  high  potential  through  a  glass  tube  that  has 
been,  as  far  as  possible,  exhausted  of  air. 

(a)  Express  in  cubic  centimeters  of  distilled  water  the 
value  of  one  ounce  avoirdupois,  (b)  How  many  minims 
does  a  cubic  centimeter  contain? 

(a)  28.3  Gc.     (b)  16.2  minims. 

What  is  hydrogen  sulphide?  Show  by  formulas  and 
equation  how  it  is  obtained  by  the  action  of  hydrochloric 
acid  on  calcium  sulphide. 

A  compound  of  sulphur  and  hydrogen,  HjS,  a  colorless 
gas  of  offensive  odor. 

CaS  +  2HC1  =CaCl2  -f  H.S. 

What  salt  forms  the  tartar  deposited  on  the  teeth? 
From  what  source  is  the  tartar  derived? 

Chiefly  calcium  phosphate,  with  a  little  calcium  carbonate, 
and  salts  of  the  alkalies.  These  salts  are  mixed  with  silica, 
organic  matter  and  bacteria.  The  tartar  is  derived  from 
food  residues  and  from  the  saliva. 

What  are  the  properties  of  antimony?  How  is  it  found 
in  nature? 

Antimony:  symbol.  Sb.  atomic  weight  119   (119.3)  valence 


CHEMISTRY.  105 

III.,  v.,  is  a  bluish-white,  brittle,  crystalline  metal.     Ignites 
at  a  red  heat,  forming  SboOg. 

Used  chiefiy  in  alloys,  it  increases  hardness,  lowei"S  fusion 
point,  gives  smoother  surface,  causes  expansion  of  alloy  when 
cooled  after  fusion,  gives  rigidity  to  soft  metals.  Antimony 
occurs  in  nature  chiefly  as  the  sulphide. 

(a)  What  is  an  amorphous  substance?  (b)  What  are 
isomorphous  substances? 

(a)  A  substance,  not  crj^stalline,  having  no  regularity  of 
internal  structure,  (b)  Substances  which  crystallize  in  the 
same  form. 

Give  uses  of  the  urinometer.  State  its  importance  as 
as  aid  to  diagnosis. 

It  is  used  to  determine  the  specific  gravity  of  the  urine. 
'I'aken  into  consideration  with  the  amount  of  urine  passed,  it 
indicates  the  amount  of  solid  matter  being  excreted  by  the 
kidney.  Certain  diseases  present  a  lessened  excretion  of 
solids,  others  an  increased  excretion;  the  determination  of 
this  factor,  then,  may  be  of  importance  in  deciding  upon  the 
condition  actually  present.  By  it  we  learn  of  the  condition 
of  the  kidney  function  and  also  of  the  body  metabolism. 

Describe  potassium. 

Potassium:  symbol,  K,  atomic  weight,  39  (38.86),  valence 
I.,  a  soft  silver-white  metal,  oxidizing  in  the  air,  and  de- 
composing water  in  the  cold  with  liberation  of  hydrogen  gas 
and  the  formation  of  pota.ssium  hydroxide.  It  melts  below 
the  boiling  point  of  water,  is  lighter  than  water,  and  is  one 
of  the  most  electro-positive  of  metals. 

Write  a  chemical  equation  showing  a  double  decompo- 
sition. 

AgNO;,  +  IICl  =  AgCl  +  UNO,. 

Give  the  physical  and  chemical  properties  of  mercury. 
How  is  mercury  obtained  from  the  native  ore? 

Mercury:  symbol.  Ilg:  atomic  weight.  198.5:  valence,  II:  is 


106  CHEMISTRY. 

a  silver-white  metal,  liquid  at  ordinary  temperatures,  131^ 
times  heavier  than  water;  it  is  volatile  at  all  temperatures, 
opaque,  insoluble  in  water,  soluble  in  nitric  acid.  Chem- 
ically, it  is  electro-positive,  and  capable  of  forming  two  dis- 
tinct classes  of  compounds — the  mercurous  and  the  mercuric 
It  forms  alloys  (amalgams)  with  most  metals.  Mercury  is 
obtained  from  cinnabar,  HgS,  by  roasting  the  ore,  thus  burn- 
ing out  the  sulphur  and  distilling  over  the  mercury. 

Define  decay. 

Decay  refers,  generally,  to  the  slow  oxidation,  resulting 
in  the  decomposition  of  organic  substances. 

Describe  distillation,  filtration  and  precipitation  as  ap= 
plied  to  processes  for  purifying  drinking  water. 

There  are  two  forms  of  distillation  practiced,  the  continu- 
ous and  the  intermittent.  In  continuous  distillation  the 
water  is  fed  constantly  into  the  retort,  and  the  distillate  con- 
tains the  gases  and  volatile  products  produced  from  the 
organic  matter  present.  Such  a  water  acquires  a  disagree- 
able odor  and  taste  on  standing,  but  is  of  course  free  from 
germ  life.  In  intermittent  distillation  a  given  amount  of 
water  is  introduced  into  the  retort,  the  first  part  of  the  dis- 
tillate is  rejected,  this  containing  the  volatile  organic  pro- 
ducts, then  a  middle  portion  is  saved,  and  the  final  portion 
left  in  the  retort  is  rejected.  By  this  process  we  get  a  pure 
water  which  requires,  however,  to  be  aerated  to  be  palatable. 

Filtration  on  a  large  scale  is  through  beds  of  sand  and 
gravel.  Suspended  matter  is  removed  and  bacteria  are  largely 
destroyed.  On  a  small  scale  filtration  is  generally  through 
porcelain,  suspended  matter  and  bacteria  are  held  back  by 
the  smallness  of  the  interstices  in  the  filtering  medium.  Such 
filters  must  be  frequently  and  thoroughly  cleansed. 

Precipitation  is  effected  by  the  addition  to  the  water  of 
one  or  more  substances  which  shall  produce  a  voluminous, 
more  or  less  gelatinous,  precipitate.  In  this  will  be  carried 
down  the  suspended  matter  and  the  major  part  of  the  germ 


CUEMISTBY.  107 

life.     Iron  salts,  and  alum,  are  among  the  chemicals  gener- 
ally used. 

What  is  freezing?  State  the  Fahrenheit  freezing  point 
of  (a)  water,  (b)  alcohol,  (c)  mercury. 

Freezing  is  the  change  of  a  liquid  to  a  solid  upon  the  lower- 
ing of  temperature. 

(a)  32^  F.     (b)  —40=  F.     (c)  202.9°  F. 

Complete  the  following  equation: 
CoHgOH  +  NaC^HgO^  +  H2SO,  = 

CoH.C^HgO^  +  NaHSO,  -f-  H.,0. 

Explain  the  difference  between  a  sulphate  and  a  sul- 
phite. 

A  sulphate  is  a  salt  of  sulphuric  acid  and  contains  the 
acidulous  radical,  SO4. 

A  sulphite  is  a  salt  of  sulphurous  acid  and  contains  the 
acidulous  radical,  SOg. 

Name  the  elements  in  the  potassium  group,  and  give 
their  physical  and  chemical  properties. 

Lithium,  sodium,  potassium,  and  the  rare  metals,  rubidium 
and  caesium. 

All  are  white  metals,  the  softest  being  but  little  harder  than 
wax.  They  melt  below  the  boiling-point  of  water,  oxidize  in 
air,  decompose  water  liberating  hydrogen.  All  are  strongly 
electro-positive,  forming  strong  alkaline  bases — oxides  and 
hydroxides.  Each  communicates  a  distinctive  color  to  flame 
when  incandescent.  All  are  monads,  their  carbonates  all 
vaporize  unchanged  when  heated.  The  carbonates  and  phos- 
phates of  all  are  freely  soluble  in  water. 

Describe  the  element  silver,  stating  its  compounds  and 
their  uses  in  medicine. 

Silver:  symbol.  Ag.  atomic  weight  107  ("107.12),  valence  I.. 
u  pure  white  metal,  ductile  aud  malleable,  the  best  conductor 
of  heat  and  electricity.    Specific  gravity,  10.5. 


108  CHEMISTRY. 

Silver  wire  is  used  in  surgery. 

The  compounds  used  in  medicine  are  the  oxide,  nitrate, 
the  cyanide  and  iodide.  The  nitrate  is  used  in  the  solid 
state  as  a  stimulant  and  caustic,  and,  internally,  in  solution, 
as  an  astringent  and  alterative  especially  in  stomach  and 
bowel  disturbances. 

Name  five  compounds  of  nitrogen  and  oxygen,  and  give 
their  formulas. 

Nitrous  oxide  or  nitrogen  monoxide,  NgO ;  nitric  oxide  or 
nitrogen  dioxide,  NoOg;  nitrous  anhydride  or  nitrogen  tri- 
oxide,  N2O3 ;  nitric  anhydride  or  nitrogen  pentoxide,  N2O5 ; 
nitric  peroxide  or  nitrogen  tetroxide,  N2O4  or  2(N02). 

What  is  the  presumption  as  to  abnormal  constituents  in 
urine  having  a  specific  gravity  of  1005  or  less?  What 
tests  should  be  applied,  and  how,  to  verify  the  surmise? 

It  indicates  a  greatly  decreased  excretion  of  solids  by  the 
kidneys  or  an  excessive  polyuria;  this  may  be  due  to  lack  of 
nervous  control  over  excretory  function  of  kidney,  as  in 
hysteria,  chorea,  etc.,  or  it  may  be  from  large  imbibition  of 
fluids.  It  may  be  due  to  diseased  conditions  of  kidney  with 
destructive  changes  in  structure.  Such  a  low  specific  grav- 
ity always  calls  for  a  careful  examination  for  albumin,  which, 
if  present  and  accompanied  by  urinary  casts,  would  indicate 
a  structural  disease  of  the  kidneys.  Tests  for  albumin  have 
been  given. 

What  are  the  differences  between  common  alcohol  and 
absolute  alcohol? 

Absolute  alcohol  contains  not  more  than  1  per  cent,  of 
water  and  this  is  in  chemical  combination  with  the  alcohol. 
Sp.  gr.  not  higher  than  0.797  at  15.6°  C. 

Common  alcohol  contains  about  7.7  per  cent,  of  water,  par- 
tially in  mixture  and  partially  in  combination  with  the  alcohol. 
Sp.  gr.  about  0.816  at  15.6°  C. 


CHEMISTRY.  109 

Complete  the  following  equations: 
C2H5CI  + AgHO  = 
CaCO,  -h  2HCI  =. 

C2H3CI  +  AgHO  =  AgCl  +  C2H5OH. 
CaCOg  +  2HC1  =  CaCla  +  H^O  +  CO.,. 

What  are  the  physical  and  chemical  properties  of  SO2? 

It  is  a  heavy  colorless  gas,  dissolving  in  and  chemically  com- 
bining with  water  to  form  sulphurous  acid.  It  has  a  suffo- 
cating, irrespirable  odor,  can  be  liquefied  and  solidified.  It 
will  not  support  combustion  nor  will  it  burn.  It  has  a  power- 
ful affinity  for  moisture,  forming,  therewith,  sulphurous  acid. 
Sulphur  dioxide  is  useful  as  a  bleaching  agent  and  as  a 
disinfectant. 

What  is  reduced  iron  (ferrum  redactum)  and  how  is  it 
obtained? 

It  is  a  chemically  pure  form  of  iron  occurring  in  fine 
powder.  It  is  obtained  by  passing  dry  hydrogen  gas  over 
heated  ferric  oxide  in  a  tube. 

Describe  ethyl  oxide,  giving  derivation,  ordinary  name, 
chemical  formula  and  mode  of  production. 

Ethyl  oxide,  ordinary  ether,  (C.,H.,)20,  is  obtained  by  the 
replacement  of  two  hydrogen  atoms  in  a  molecule  of  water 
by  two  ethyl  radicals.  It  is  manufactured  by  distilling  a 
mixture  of  alcohol  and  sulphuric  acid. 

C^H.OH  -f  H2SO,  =  C^H.HSO,  +  H^O ; 

C^H.HSO,  +  CjH.OH  =  (C2HJ2O  -f  H^SO,. 

What  is  the  presumption  as  to  abnormal  constituents  in 
urine  having  a  specific  gravity  of  1038? 

Such  urine  will  probably  be  found  to  contain  glucose. 

Give  an  equation  showing  the  reaction  when  NH,  comes 
in  contact  with  an  acid. 


NH, -hHCl  =  NH«Cl. 


no  CHEMISTRY. 

Define  emulsion,  soap. 

An  emulsion  is  a  liquid  holding  in  suspension  oil  in  so  finely 
divided  a  condition,  that  the  individual  drops  are  invisible 
to  the  naked  eye.  There  is  generally  required  to  be  present 
a  substance  of  mucilaginous  nature. 

A  soap  is  a  metallic  salt  of  a  fat  acid.  It  is  usually  a 
potassium  or  sodium  salt  of  oleic,  stearic  or  palmitic  acid. 

Give  the  sources  and  explain  the  uses  of  benzene. 

CoHfi,  benzene.  It  is  found  in  the  lighter  oils  produced  in 
the  distillation  of  coal  tar. 

It  is  used  as  a  solvent  for  fats,  oils,  resins,  and  many  other 
organic  substances.  Used  in  medicine  as  an  antispasmodic 
and  anticatarrhal  remedy. 

What  is  an  alkaloid?  Name  three  alkaloids  used  in 
medicine. 

An  organic  nitrogenous  substance,  basic  in  character,  cap- 
able of  combining  directly  with  acids  to  form  salts.  The 
volatile  alkaloids  contain  carbon,  hydrogen,  and  nitrogen; 
the  non-volatile  alkaloids  contain  carbon,  hydrogen,  nitrogen, 
and  oxygen.     Examples:  strychnine,  quinine,  and  morphine. 

State  the  chemical  meaning  of  the  term  incompatible. 

Chemically,  substances  are  incompatible  when  on  mixing 
their  solutions  there  results  an  insoluble  body,  or  a  new  sub- 
stance having  markedly  different  properties;  or  when  two  or 
more  substances,  in  themselves  hannless,  form  a  poisonous, 
explosive,  or  inflammable  substance  when  brought  in  contact; 
or  if  bringing  them  together  impairs  in  any  other  way  their 
individual  characteristic  properties. 

State  the  use  and  the  principal  underlying  the  use  of 
the  blow=pipe. 

The  blow-pipe  serves  to  provide,  and  to  concentrate  at  a 
particular  point,  a  jet  of  flame  of  extremely  high  temperature, 
this  high  temperature  being  attained  by  the  perfect  combus- 
tion resulting  from  the  mixing  of  air  with  the  gas  before  the 
latter  burns. 


CHEMIST  BY.  Ill 

Define  electricity. 

Electricity  is  that  physical  force  generated  by  chemism, 
magnetism  or  friction,  which  manifests  itself  by  producing 
attraction  or  repulsion  between  certain  substances,  and  gives 
rise  to  heat,  light,  magnetism,  and  chemical  action. 

(a)  In  what  compound  is  sodium  most  abundant?  (b) 
In  what  calcium?     (c)  In  what  hydrogen? 

(a)  Sodium  chloride,     (b)  Calcium  carbonate,     (c)  "Water. 

What  is  glycerin  and  how  is  it  obtained? 

Glycerin,  CgHgOg,  or  C3H-(OH)3.  It  is  a  tri-atomic  alcohol 
derived  from  propane,  CJlg.  Made  by  decomposing  fat  either 
by  means  of  superheated  steam,  or  by  heating  the  fat  with 
an  alkali. 

Explain  the  difference  between  a  galvanic  and  a  faradic 
current. 

A  galvanic  current  results  from  chemical  action,  and  has 
but  low  potential  with  large  quantity.  Its  direction  of  flow 
is  always  the  same.  A  faradic  current  is  an  induced  current 
obtained  by  use  of  an  induction  coil.  Such  a  current  pos- 
sesses high  potential,  small  quantity,  and  its  direction  of  flow 
is  to  and  fro,  or  alternating. 

What  products  of  phenol  are  of  interest  in  medicine? 

The  phenates  or  carbolates.  e.  g.,  sodium  phenate :  the 
phenolsulphonates,  and  trinitrophenol  or  picric  acid.  Sali- 
cylic acid  and  its  various  products  may  be  synthetically  pro- 
pared  from  phenol. 

Designate  the  following  as  chemical  or  physical  changes: 
(a)  The  souring  of  milk,  (b)  Decomposition  of  sunlight 
by   means   of  prisms,     (c)   Converting  water   into  steam. 

(d)  Dissolving  salt  in  water,     (e)  Decay  of  wood. 

(a)  Chemical:    (b)    physical;   (c)   physical;    (d)    physical; 

(e)  chemical. 

Mention  the  chief  properties  of  nitrogen. 

Nitrogen:   Nvmbol   N.   atomic   weight.    14    ("13.93).   valence 


112  CHEMISTRY. 

III.,  v.,  is  a  colorless,  odorless,  tasteless  gas,  a  little  lighter 
than  air,  incombustible,  a  non-supporter  of  combustion,  does 
not  support  life,  is  not  poisonous. 

What  metal  is  liquid  at  ordinary  temperature? 

Mercury. 

Mention  a  substance  containing  albumin,  (a)  as  a  liquid, 
(b)  as  a  solid. 

(a)  Blood,  (b)  Albumin  exists  naturally  only  in  solu- 
tion, an  example  of  a  solid  (coagulated)  albumin  would  be 
the  white  of  a  hard-boiled  egg. 

What  is  the  chemical  cause  of  spontaneous  combustion? 

An  active  oxidation  or  other  chemical  change  resulting 
in  the  development  of  sufficient  heat  to  cause  self-ignition. 

Describe  a  test  for  the  presence  of  organic  matter  in 
water. 

Distill  the  water  until  free  from  ammonia,  then  add  to 
the  residue  in  the  retort  an  alkaline  solution  of  potassium 
permanganate,  when  if,  on  again  distilling,  ammonia  ap- 
pears in  the  distillate,  the  presence  of  organic  matter  would 
be  indicated. 

Give  the  names  and  formulas  of  five  acids  used  in  med= 
icine. 

Nitric  acid,  HNO3;  sulphurous  acid,  H2SO3;  hydrochloric 
acid,  HCl;  phosphoric  acid,  HgPO^;  acetic  acid,  HCgHgOo. 

Mention  the  elements  existing  uncombined  in  nature. 

Hydrogen,  oxygen,  nitrogen,  carbon,  sulphur,  gold,  silver, 
platinum,  copper,  mercury,  and  a  few  other  metals. 

What  is  carbon  dioxide?  Give  its  formula,  properties, 
uses,  and  mode  of  production. 

Carbon  dioxide,  COg,  a  colorless  gas,  generally  with  a  faint 
acid  odor,  soluble  in  water,  a  non-supporter  of  combustion 
and  incombustible.  It  will  not  support  life  but  is  non-pois- 
onous. Carbon  dioxide  is  produced  by  respiration  of  ani- 
mals, by  the  complete  burning  of  carbonaceous  matter,  by 


CHEMISTRY.  Ui 

heating  many  metallic  carbonates,  and  by  treating  carbon- 
ates with  acids.  It  is  used  in  making  "'  soda  water  "  and 
other  artificial  effervescent  drinks;  liquefied  CO2  is  used  for 
freezing  purposes.     It  is  essential  to  plant  life. 

When  and  why  is  a  flame  produced  by  combustion? 

When  the  combustion  is  sufficiently  rapid  and  active  to 
raise  the  temperature  to  the  ignition  point. 

Give  the  preparation  of  Fowler's  solution,  and  describe 
the  salts  contained  in  it. 

Boil  one  part  arsenious  oxide  with  two  parts  potassium  bi- 
carbonate in  94  parts  water  and  add  three  parts  compound 
tincture  of  lavender.  The  solution  so  made  contains  potas- 
sium metarsenite,  an  easily  soluble  compound  of  arsenic,  not 
used  in  the  solid  state. 

As/J,  +  2KHCO3  =  2KASO2  +  H2O  -f  2C0,. 

What  is  chloroform  and  how  is  it  made? 

Chloroform,  triehlormethane,  CHCI3.  It  is  a  heavy  color- 
less liquid,  specific  gravity  of  1.5,  with  a  characteristic  etherial 
odor  and  a  sweet  burning  taste.  Boils  at  60-61°  C.  Pre- 
pared by  the  action  of  "  bleaching  powder  "  on  alcohol,  by 
the  action  of  "  bleaching  powder  "  on  acetone,  and  by  the 
a-ction  of  an  alkali  on  chloral. 

Describe  and  illustrate  alcoholic  fermentation. 

Alcoholic  fermentation  is  the  decomposition  of  a  sugar  by 
a  ferment,  with  the  production  of  carbon  dioxide  and  alcohol. 

CJI.aOe  =  2CO2  +  2C2H5OH. 
What    is    ethyl    hydrate?      Give    its    formula    and    state 
how  it  is  produced. 

p]thyl  hydrate,  CgHjiOH,  is  ordinary  alcohol.  It  is  pi"o- 
duced  by  the  fermentation  of  glucose. 

Complete  the  following  equations: 
2NaCI  +  Ag.SO,= 
BaO,  +  CO.  +  H,0  = 

2NaCl  -f  Ag^SO,  =  2AgCl  -f  Na,SO,. 
BaO.,  4-  CO2  -f  H^O  =  BaCOg  +  H„0,. 

8 


114  CHEMISTRY. 

Define  matter. 

Matter  is  that  which  has  weight  and  occupies  space. 

Define  and  illustrate  osmose. 

Osmose,  or  osmosis,  is  that  property  by  which  liquids  and 
certain  substances  in  solution  pass  through  porous  partitions. 
Thus,  if  copper  sulphate  in  solution  be  placed  in  an  un- 
giazed  earthenware  vessel,  and  this  be  set  in  a  larger  vessel 
containing  distilled  water,  the  salt  will  pass  through  into  the 
water  (exosmosis),  while  the  liquid  in  the  inner  vessel  will 
increase  in  quantity  ( endosmosis) . 

Give  an  illustration  of  decomposition  by  (a)  heat,  (b) 
electricity,  (c)  light. 

(a)  Mercuric  oxide  heated,  yields  oxygen  and  mercury. 

(b)  Pass  a  galvanic  current  through  water  and  the  latter 
will  be  decomposed,  hydrogen  and  oxygen  being  set  free. 

(c)  Expose  silver  chloride  to  the  action  of  sunlight;  it  un- 
dergoes decomposition,  producing  a  subchloride  of  silver,  and 
changing  in  color  from  white  to  grayish-violet. 

What  is  a  compound  radical?  Give  three  examples  of 
compound  radicals,  indicating  the  valence  of  each. 

A  compound  radical  is  a  group  of  atoms  capable  of  play- 
ing the  part  of  an  elementary  substance  and  incapable  of 
existing  in  the  free  state. 

Examples :  NO3,  valence  I. ;  SO4,  valence  II. ;  PO4,  valence 
III. 

Describe  the  medicinal  uses  of  oxygen,  stating  how  it  is 
brought  to  the  bedside  and  how  it  is  applied. 

Oxygen  gas  subjected  to  pressure  is  liquefied  and  stored  in 
steel  cylinders.  The  gaseous  oxygen  from  the  cylinder  is 
conducted  into  a  rubber  bag,  and  from  this  through  a  wash 
bottle  containing  a  small  quantity  of  water.  In  the  use  of 
the  oxygen  we  secure  a  continuity  of  flow  by  allowing  the  bag 
to  fill  with  the  gas  and  then  compressing  it.  Oxygen  is  in- 
dicated wherever  respiration  is  embarrassed,  in   pneumonia. 


CHEMilSTKY.  115 

pleurisy,  asthma,  etc.    It  is  also  used  for  its  general  stimulant 
effect. 

State  the  composition,  mode  of  preparation  and  prop= 
erties  of  sal  ammoniac. 

Sal  ammoniac,  ammonium  chloride,  NH^Cl,  prepared  by 
saturating  hydrochloric  acid  with  ammonia.  It  is  a  white 
crystalline  soluble  substance  with  saline  taste  and  neutral 
properties.  It  yields  ammonia  gas  when  heated  with  strong 
bases.  Used  in  medicine  as  an  alterative  and  as  a  stimulating 
expectorant. 

What  are  the  distinguishing  characteristics  of  urates 
and  of  uric  acid  as  deposited  in  the  urine? 

Uric  acid  is  deposited  in  reddish  grains  which  settle  rap- 
idly to  the  bottom  of  the  vessel  and  are  not  dissolved  on 
warming. 

Urates  form  generally  a  more  bulky  sediment,  pink  or  white 
in  appearance,  settling  more  slowly,  and  easily  dissolved  on 
warming. 

Both  uric  acid  and  urates  respond  to  the  murexid  test. 
Under  the  microscope  uric  acid  appears  in  yellowish  lozenge- 
shaped  crystals  often  in  rosette-like  groups,  while  urates  aro 
generally  amorphous  or  semi-crystalline. 

Mention  two  substances  that  are  fusible,  two  substances 
that  are  volatilized  by  heat,  two  substances  that  are  un- 
affected by  heat. 

Lead  and  iron  are  fusible.  Iodine  and  sulphur  volatilize. 
Carbon  and  silicon  in  absence  of  air.  are  unaffected  by  heat. 

Describe  iron  and  its  preparations.  Why  is  iron  pre- 
.scribed  in  anemic  conditions? 

Iron:  symbol,  Fe,  atomic  weight,  56  (55.5),  valence  II., 
TV.,  (FcaVI),  specific  gravity  7.84.  a  gray-white  metal,  with 
very  high  melting  point,  the  most  tenacious  of  metals,  duetilf 
and  malleable. 

It  oxidizes  in  air  in  the  presence  of  moisture  and  oeeui-s 
in  nature  ehieflv  in  the  form  of  oxides. 


116  CHEMISTRY. 

Preparations  frequently  used:  Ferric  chloride,  ferric  sul- 
phate, ferric  acetate,  ferric  hydroxide,  ferrous  sulphate,  fer- 
rous carbonate,  and  the  metal  itself;  organic  salts  of  the 
metal,  as  the  peptonate,  albuminate,  citrate,  and  tartrate. 

Iron  is  prescribed  in  anemic  conditions  to  afford  the  neces- 
sary element  for  the  making  of  red  blood  corpuscles. 

Give  illustrations  differentiating  combustion,  fermenta= 
tion,  putrefaction  and  decay. 

Heat  wood  in  air  and  it  undergoes  change  into  carbon 
dioxide,  water,  and  a  residue,  called  ash.  This  change,  com- 
bustion, is  accompanied  by  a  rise  in  temperature  and  the 
production  of  a  flame.  Wood  exposed  to  air  and  moisture 
for  a  lengthy  period  of  time,  slowly  undergoes  destructive 
change,  a  decay,  yielding  finally  the  same  products  as  those 
produced  in  combustion. 

Fermentation  is  the  decomposition  of  complex  substances 
by  organized  ferments,  or  by  enzymes.  As  an  example  we 
have  the  conversion  of  glucose  into  alcohol  and  carbon  dioxide 
by  the  organized  ferment,  yeast. 

Putrefaction  is  the  decomposition  of  nitrogenous  organic 
matter  by  the  action  of  bacteria. 

Explain  the  use  of  symbols  and  formulas.  Give  and 
translate  five  examples  of  each. 

A  symbol  is  used  as  a  representation  of  one  atom  of  an 
elementary  substance.  A  formula,  an  aggregation  of  symbols, 
represents  one  molecule  of  a  substance. 

Oxygen,  O ;  chlorine,  CI ;  bromine,  Br ;  nitrogen,  N ;  hydro- 
gen, H. 

HNO3,  nitric  acid;  H2SO4,  sulphuric  acid;  PbO,  litharge; 
NHg,  ammonia ;  NaCl,  sodium  chloride. 

What  is  the  source  of  tartaric  acid?  What  is  its  use  in 
medicine? 

It  is  obtained  from  argol,  the  impure  cream  of  tartar  de- 
posited during  the  fermentation  of  grape  .juice.  It  is  used 
pure  in  the  seidlitz  powder,  occasionally  as  an  antiscorbutic, 


CHEMISTRY.  117 

etc.     Used  chiefly  in  the  form  of  its  salts,  cream  of  tartar, 
Koehelle  salt,  and  tartar  emetic. 

Explain  the  principle  of  the  action  of  yeast. 

Under  favoring  conditions  of  proper  temperature,  presence 
of  moisture,  and  of  air,  the  yeast  plant  causes,  by  its  growth, 
such  a  rearrangement  of  the  atoms  of  C,  H  and  0  in  glucose 
as  to  produce  from  one  molecule  of  glucose  two  molecules  of 
alcohol  and  two  molecules  of  carbon  dioxide  gas. 

How  is  an  excess  of  urates  determined  In  a  sample  of 
urine? 

To  200  Cc.  of  urine  add  20  Cc.  of  strong  hydrochloric  acid 
and  let  the  mixture  stand  48  hours.  The  urates  will  be  de- 
composed and  uric  acid  deposited.  Collect  the  sediment  on 
a  previously  weighed  filter  paper,  wash,  dry,  and  weigh  again. 

What  antidote  should  be  employed  in  a  case  of  strych- 
nine poisoning? 

At  once  administer  an  emetic  and  tannic  acid,  then  give 
potassium  bromide  in  drachm  doses;  if  convulsions  occur  use 
inhalation  of  ether  or  chloroform.  Use  rectal  injections  of 
chloral,  etc. 

Define  hydride,  specific  heat,  haloid  salt. 

A  hydride  is  a  binary  compound  containing  hydrogen  and 
one  other  element. 

By  specific  heat  we  mean  the  amount  of  heat  given  off  or 
absorbed  by  a  definite  weight  of  a  substance  in  undergoing  a 
Tneasured  change  of  temperature,  as  compared  with  the 
amount  of  heat  given  off  or  absorbed  by  an  equal  weight  of 
water  in  undergoing  the  same  change  in  temperature. 

A  haloid  salt  is  one  containing  a  metal  or  basic  radical  in 
combination  with  a  member  of  the  halogen  or  chlorine  group. 

In  what  respect  does  sterilized  milk  differ  from  raw 
milk? 

The  sterilizing  of  milk  coagulates  the  lactalbumin  and  the 
globulin,  and  modifies  the  casein.    On  acidifying  the  sterilized 


118  CHEMISTRY. 

milk  all  the  proteids  are  precipitated  at  ouce  in  a  firm  eurd 
not  easily  digested.  In  sterilizing  milk,  germs  that  may  be 
present  are  killed. 

Complete  the  following  equations  and  write   the  name 
of  each  resulting  compound  under  its  formula: 
AS2O3  -|-  3H2S  = 
H2SO4  +  NaNOg  = 

AS3O3  +  3H2S  =  AS2S3  +  3H2O 

Arsenic  trisulphide.  Water. 

H2SO4  +  NaNOs  =  NaHSO,  +  HNO3 

Sodium  hydrogen  sulphate.  Nitric  acid. 

Explain  the  chemistry  of  a  candle  flame. 

Candle  flame  shows  three  distinct  zones:  Inner  one  con- 
sisting of  vaporized  hydrocarbons  gives  no  illumination  and 
scarcely  any  heat.  Middle  flame,  the  illuminating  flame, 
consists  of  solid  carbon  in  fine  subdivision  rendered  incan- 
descent by  the  heat  due  to  the  combination  of  oxygen  with 
hydrocarbon  vapors,  gives  a  large  amount  of  heat.  Third  or 
surrounding  zone,  darker  in  color,  contains  solid  particles  of 
carbon,  as  soot,  also  carbon  dioxide  and  vapor  of  water,  as  a 
result  of  the  burning  of  the  hydrocarbon  vapors,  supplies 
but  little  heat  or  light. 

Write  the  chemical  name  and  formula  for  laughing  gas. 

Nitrous  oxide,  or  nitrogen  monoxide,  N2O. 

What  is  the  chemical  change  which  occurs  in  the  making 
of  malt? 

Starch  under  the  action  of  a  ferment  is  changed  to  maltose, 
throug'h  chemical  union  with  water. 

2CeH,oO,  +  H20  =  C,3H2Ai. 

Explain  how  water  containing  organic  impurities  may 
become  purified  by  running  in  a  shallow  stream  or  over  a 
precipice. 

All  parts  of  the  water  and  its  contained  impurities  are 
brought  in  contact  with  atmospheric  oxygen;  the  organic 
matter  is  oxidized  and  decomposed. 


CHEMISTRY.  119 

What  is  ammonium? 

Ammonium,  NH^,  is  a  basic  radical  forming  compounds 
similar  to  those  of  the  alkali  metals.  Its  relation  to  ammonia, 
NH3,  is  shown  in  the  manner  of  formation  of  its  compounds, 
e.  g.,  ammonium  chloride,  NH3  +  HCl  =  NH^Cl. 

Mention  a  test  of  CO2,  and  also  its  chief  properties. 

When  passed  into  clear  lime-water  it  produces  a  white 
precipitate  of  calcium  carbonate.  Carbon  dioxide  is  a  gas 
about  11/2  times  the  weight  of  air,  a  non-supporter  of  com- 
bustion and  incombustible,  produced  by  the  complete  oxida- 
tion of  carbon.  It  is  colorless,  has  a  faint  acid  odor,  and  is 
soluble  in  water. 

What  elements  enter  into  the  composition  of  all  alka= 
loids? 

Carbon,  hydrogen,  nitrogen,  in  volatile  alkaloids.  Carbon, 
hydrogen,  nitrogen  and  oxygen,  in  fixed  alkaloids. 

Explain  an  experiment  to  prove  that  chemical  action 
may  be  induced  by  light. 

The  sun's  rays  or  diffused  daylight  Avill  bring  about  chem- 
ical union  between  hydrogen  and  chlorine  to  form  hydro- 
chloric acid,  this  union  being  accomplished  with  explosive 
violence  in  direct  light,  but  more  slowly  if  the  light  be 
<liffused. 

What  is  the  technical  name  of  (a)  aqua  regia,  (b)  aqua 
fortis,  (c)  oil  of  vitriol? 

(a)  Nitro-hydrochloric  acid;  (b)  nitric  acid;  (c)  sulphuric 
acid. 

Describe  the  properties  of  hydrogen,  and  mention  a  test 
to  prove  that  it  will  not  support  combustion. 

It  is  a  colorless,  tasteless,  odorless  gas,  lightest  of  the  well- 
kno^^-n  elementary  gases;  burns  in  air  or  oxygen;  will  not 
support  combustion  nor  animal  respiration.  It  is  strongly 
electro-positive.  A  proof  that  it  does  not  support  combustion 
is  afforded  by  plunging  a  lighted  taper  into  a  jar  of  hydro- 


120  CHEMISTRY. 

gen,  held  mouth  downward;  the  flame  of  the  taper  is  extin- 
guished, although  the  hydrogen  may  burn  at  the  mouth  of 
the  jar. 

Give  the  composition  of  aqua  ammoniae. 

Ammonium  hydroxide,  NH^OH,  is  theoretically  composed 
of  one  molecule  of  ammonia  gas,  NH3,  dissolved  in  and  chemi- 
cally combined  with  one  molecule  of  water.  The  aqua  am- 
moniae of  the  U.  S.  P.  is  an  aqueous  solution  of  ammonia 
containing  10  per  cent,  by  weight  of  the  gas. 

What  is  peroxide  of  hydrogen? 

Peroxide  of  hydrogen  or  hydrogen  dioxide,  H2O2,  in  its 
purest  form,  is  a  syrupy  liquid.  The  usual  strength  in  com- 
merce is  a  3  per  cent,  by  weight  solution  giving  off  10  volumes 
of  available  oxygen. 

Account  for  the  poisoning  property  of  illuminating  gas» 

The  poisonous  action  is  due  to  the  presence  of  carbon 
monoxide  and  in  less  degree  to  carbon  dioxide,  various  hydro- 
carbons and  sulphur  compounds. 

What  is  the  normal  reaction  of  (a)  saliva,  (b)  bile? 
What  causes  the  reaction? 

(a)  Alkaline,  from  the  presence  of  bicarbonates  and  phos- 
phates of  the  alkalies  and  alkaline  earths;  (b)  alkaline,  from 
the  presence  of  alkaline  carbonates,  and  the  sodium  salts  of 
organic  acids. 

Give  formula  for  (a)  mercuric  chloride,  (b)  sodic  sul= 
phate,  (c)  potassium  chlorate,  (d)  cupric  nitrate,  (e)  cal= 
cium  carbonate. 

(a)  HgCl^;  (b)  Na^SO, ;  (c)  KCIO3;  (d)  CuCNOa)^;  (e) 
CaCOa. 

Define  saturation. 

The  term  saturation,  applied  to  a  liquid,  means  that  the 
liquid  holds  dissolved  all  of  a  solid  or  gaseous  body  that  it  is 
capable  of  dissolving. 


CHEMISTRY.  121 

Discuss  the  value  of  sulphur  as  a  germicide. 

Sulphur  will  act  as  a  germicide  only  when  combined  with 
oxygen  to  form  sulphur  dioxide. 

In  its  germicidal  action,  the  sulphur  dioxide  extracts  mois- 
ture to  form  sulphurous  acid  and  this  acts  as  a  deoxidizing 
or  reducing  agent. 

Practically  it  must  be  remembered,  that  sulphur  dioxide 
is  a  bleaching  agent,  so  that  care  must  be  taken  to  remove 
from  the  room  colored  fabrics  of  value. 

By  what  forces  can  (a)  a  solid  be  changed  into  a  liquid 
or  a  gas,  (b)  a  gas  be  changed  into  a  liquid  or  a  solid? 

(a)  By  heat  or  by  lessened  pressure;  (b)  by  cold  or  by 
increasing  pressure. 

What  is  the  composition  of  baking  powders?  How  are 
they  adulterated?     What  is  their  mode  of  action? 

They  all  contain  sodium  bicarbonate  mixed  with  an  acid 
salt  as  potassium  bi-tartrate,  or  a  weak  acid. 

In  the  presence  of  heat  and  moisture  their  contained  chemi- 
cals react  with  the  evolution  of  carbon  dioxide, 

KHC,H,Oo  +  K^HCOs  =  KNaC.H^Oe  +  H^O  -f  CO2. 

Among  adulterants  are  alum,  flour,  chalk  and  gypsum. 

What  is  turpentine? 

Turpentine,  (",„ll,,,,  is  an  essential  oil,  a  hydrocarbon  ob- 
tained from  the  exudate  of  pine  trees. 

State  the  properties  and  uses  of  HjSO^. 

Sulphuric  acid,  II2SO4,  a  heavy  corrosive  liquid,  colorless 
when  pure  but  often  brown  from  presence  of  carbon.  It  has 
a  stong  affinity  for  water,  the  union  of  the  two  being  accom- 
panied by  the  evolution  of  heat.  It  is  one  of  the  most  im- 
portant of  all  known  manufactured  substances,  being  used 
directly  or  indirectly  in  a  great  variety  of  industries.  It  is 
an  important  chemical  reagent  and  forms  many  salts  of  im- 
portance medicinally. 


122  CREMIHTRY. 

How  does  diet  affect  the  elimination  of  urea? 

A  nitrogenous  diet  tends  to  increase  the  elimination  of  urea. 

A  restricted  diet,  starvation,  or  a  non-nitrogenous  diet 
diminishes  the  elimination  of  urea. 

Disease  accompanied  by  rapid  or  long-continued  tissue 
changes,  as  during  high  fevers,  may  be  accompanied  by  in- 
creased elimination  of  urea  even  in  the  absence  of  a  nitro- 
genous diet. 

What  are  bromides,  iodides,  chlorides? 

Bromides  are  salts  of  hydrobromic  acid;  iodides  are  salts, 
of  hydriodic  acid ;  and  chlorides  are  salts  of  hydrochloric  acid. 

Write  the  formula  of  (a)  sulphurous  acid,  (b)  acetic 
acid,  (c)  hydrochloric  acid,  (d)  water,  (e)  cupric  sulphate. 

(a)  H2SO3;  (b)  HC2H3O2;  (c)  HCl;  (d)  H^O;  (e)  CuSO^. 

What  are  mineral  waters? 

Mineral  waters  are  such  waters  as  contain  too  great  a  quan- 
tity of  dissolved  mineral  salts  to  warrant  their  use  for  ordi- 
nary drinking  purposes. 

They  possess  various  medicinal  virtues  in  accordance  with 
the  particular  kind  of  mineral  salts  contained. 

Give  the  composition  of  water  by  volume  and  by  weight. 

Water  is  composed  of  two  volumes  of  hydrogen  and  one 
volume  of  oxygen. 

Water  is  composed  of  two  parts  by  weight  of  hydrogen 
Avith  16  parts  by  weight  of  oxygen. 

Give  test  for  the  presence  of  sulphuric  acid  in  vinegar. 

To  vinegar  add  a  few  drops  of  a  solution  of  barium  nitrate, 
when,  should  sulphuric  acid  be  present,  there  will  form  a 
white  precipitate  insoluble  in  acids. 

How  may  the  presence  of  arsenic  in  wall=paper  be  de= 
tected? 

Use  the  Reinseh  test:  The  paper,  torn  into  fragments,  is 
placed  in  a  beaker  along  with  hydrochloric  acid  and  water, 
bring  to  a  boil  and  introduce  a  strip  of  clean  copper  foil. 


CHEMISTKY.  123 

If  a  gray  coating  form  on  the  copper,  dry  it  carefully  and 

heat  in  an  ignition  tube.  If  the  coating  be  due  to  arsenic 
it  will  be  volatilized  and  will  deposit  on  the  cooler  portion  of 
the  tube  in  crystals  of  arsenious  oxide. 

What  chemical  changes  take  place  in  decaying  bodies? 

All  the  body  tissues  including  the  complex  albuminoid  sub- 
stances are  split  up,  by  decomposition,  into  simple  substances. 
Among  these  products  of  decomposition  are  peptones, 
ptomaines,  leucin,  tyrosin,  amines,  acids,  ammonia,  ammo- 
nium sulphide,  hydrogen  sulphide,  etc.  Finally  we  have  pro- 
duced, simply,  water,  carbon  dioxide,  ammonia,  hydrogen  sul- 
phide, and  mineral  residues. 

What  is  the  antidote  for  poisoning  from  hydrocyanic 
acid? 

Hydrogen  dioxide.  There  is  also  used  a  solution  of  mixed 
ferrous  and  ferric  sulphates  with  sodium  or  potassium  hy- 
droxide or  carbonate  added.  Use  ammonia  by  inhalation, 
artificial  respiration,  faradism  to  the  heart. 

What  antidotes  should  be  used  in  phosphorus  poison- 
ing?    Why? 

Copper  sulphate  in  solution  acts  antidotally  to  phosphorus 
through  producing  an  insoluble  copper  phosphide. 

Old  French  ozonized  oil  of  turpentine  acts  as  an  antidote 
to  phosphorus,  by  oxidizing  it  to  a  comparatively  harmless 
form. 

What  double  salts  of  tartaric  acid  are  used  in  medicine? 

Double  tartrate  of  potassium  and  sodium,  or  Rochelle  salt. 
■   Double   tartrate    of    potassium    and    antimony    (SbO),    or 
tartar  emetic. 

Double  tartrate  of  potassium  and  hydrogen,  or  cream  of 
tartar. 

Mention  five  common  vegetable  poisons,  and  state  the 
antidote  for  one  of  them. 

Opium,   belladonna,   aconite,  digitalis,   nux  vomica. 


124  CHEMISTRY. 

Antidotes  to  opium  are  permanganate  of  potassium,  atro- 
pine, caffeine. 

Describe  the  preparation  of  hydrogen  dioxide,  writing 
the  reaction.    Give  uses  of  hydrogen  dioxide. 

Mix  barium  dioxide  with  water,  pass  CO2  gas  through 
the  mixture,  filter,  concentrate  the  filtrate  by  evaporation  in 
vacuum  over  strong  sulphuric  acid.  BaOg  +  HgO  +  COj  = 
BaCOs  -j-  HgOo.  Made  also  by  the  action  of  an  acid  on  barium 
dioxide,  BaO^  +  H2SO4  =  BaSO^  +  H^O^.  Uses :  For  bleach- 
ing, disinfection  and  for  destroying  pus;  it  is  a  strong  oxid- 
izing agent. 

Complete  the  following  equations: 
CUSO4  +  2KOH  = 
NaHCOg  -f  HCl  = 

CuSO^  +  2K0H  =  Cu(OH)  2  +  K2SO,. 
NaHCOa  +  HCl  =  NaCl  +  H.O  +  CO^. 

Describe  an  electric  battery,  and  explain  the  operation 
of  the  chemicals  used. 

An  electric  batery  is  composed  of  several  cells.  An  elec- 
tric cell  may  be  made  as  follows:  Two  plates  of  dissimilar 
substances  are  immersed  in  an  acid  or  other  fluid  which  acts 
upon  one  of  the  substances  more  than  upon  the  other.  If 
these  two  plates  are  joined  outside  of  the  cell  by  a  wire  a 
current  of  electricity  will  flow  from  one  plate  to  the  other 
through  the  liquid,  returning  by  the  connecting  wire.  If  the 
plates  are  made  of  carbon  and  zinc,  and  the  solution  used  is 
dilute  sulphuric  acid,  the  zinc  plate  will  gradually  dissolve, 
zinc  sulphate  will  accumulate  in  the  solution,  and  hydrogen 
gas  will  be  given  off  at  the  carbon  plate.  The  current  is 
said  to  flow  from  the  zinc  to  the  carbon  through  the  liquid, 
and  from  the  carbon  to  the  zinc  through  the  connecting  wire. 

Give  the  sources  and  uses  of  ammonia  in  medicine  and 
in  the  arts. 

Ammonia  is  obtained  from  the  ammoniacal  liquor  produced 
in  the  manufacture  of  illuminating  gas  from  coal.     The  gas 


CHEMISTRY.  125 

may  be  obtained  in  a  pure  state  by  heating  a  salt  of  ammon- 
ium with  a  strong  base. 

Ammonia  is  used  in  medicine  as  a  cardiac  and  a  general, 
quickly-acting,  stimulant.  In  the  arts  it  is  used  as  a  volatile 
base,  as  a  cleansing,  detergent  substance,  as  an  ant-acid. 

Show  by  equation  how  nitric  acid  is  formed  by  the  action 
of  sulphuric  acid  on  potassium  nitrate.  How  is  nitric  acid 
distinguished  from  the  other  mineral  acids? 

2KNO3  +  II^SO,  =  2HNO3  +  K,SO,. 
Nitric  acid  in  contact  with  metallic  copper  yields  a  greenish- 
blue  liquid,  and  gives  rise  to  orange-red  fumes  of  N2O4,  this 
action  not  being  brought  about  by  any  other  of  the  mineral 
acids. 

Indicate  by  chemical  sign  and  symbols  the  reactions 
that  occur  when  (a)  a  phosphorus  match  is  lighted  in  the 
air,  (b)  sodium  is  placed  on  the  surface  of  the  water,  (c) 
hydrochloric  acid  is  poured  on  marble,  (d)  two  portions 
of  seidlitz  powder  are  mixed  in  water. 

(a)  P, +  air(502)=2P20,. 

(b)  Na,  -f  H2O  =  Na^O  +  H^ ;  then  Na^O  +  H.O  =  2NaOH. 

(c)  2HC1  +  CaCO,  =  CaCl^  -f  H^O  +  CO^. 

(d)  KNaCJI.Oe  +  NaHCOs  +  H^CJI.Oe  = 

KNaCJI^Oe  +  NaHC,H,Oe  +  II^O  +  CO^. 

Describe  the  chemistry  of  alcohols  and  ethers. 

An  alcohol  is  a  compound  of  a  hydrocarbon  radical  with 
hydroxyl. 

An  ether  is  an  oxide  of  a  hydrocarbon  radical. 

What  treatment  is  indicated  in  a  case  of  poisoning  by 
mercuric  chloride? 

Administer  albumin,  of  eggs,  milk,  flour,  etc.,  and  then 
use  stomach  pump,  or  emetic,  to  at  once  remove  the  newly 
formed  albuminate  of  mercury.  Repeat  this  process  several 
times. 


126  CHEMISTRY. 

Explain  the  constitution  of  the  fats  and  the  process  of 
saponification. 

A  fat  is  a  chemical  union  of  glycerin  with  a  fat  acid. 

If  a  base,  such  as  caustic  potash,  be  boiled  with  a  fat,  the 
glycerin  is  separated  from  the  acid,  and  the  latter  combines 
with  the  base  to  form  a  salt  known  as  a  soap. 

Complete  the  following  equations: 
AgNOg  +  NaCI  = 
Si02  +  HF  = 

AgNOs  +  NaCl  =  AgCl  +  NaNOg. 
SiO^  +  4HF  =  SiF,  +  2H2O. 

Find  the  weight  and  the  volume  of  hydrogen  contained 
in  17  grams  of  NH,. 

The  atomic  weight  of  nitrogen  is  14,  of  hydrogen  1,  the 
molecular  weight  of  NH3  is,  therefore,  17,  and  in  17  grams 
of  NH3  there  must  be  3  grams  of  hydrogen.  One  litre  of 
hydrogen  weighs  0.0899  gram ;  three  grams  of  hydrogen,  then, 
must  measure  33.48  litres  (3  -^  0.0899) . 

What  is  sulphuretted  hydrogen?  Give  its  formula, 
property  and  uses. 

Sulphuretted  hydrogen  or  hydrogen  sulphide,  HgS  is  a 
colorless  gas,  slightly  heavier  than  air,  of  offensive  odor  and 
poisonous  action.  It  is  soluble  in  water,  and  burns  in  air 
with  a  blue  flame,  forming  sulphur  dioxide  and  water.  It  is 
used  as  a  group  reagent,  precipitating  a  number  of  metals 
in  the  form  of  insoluble  sulphides. 

Name  and  give  the  formulas  of  three  important  salts  of 
potassium  used  in  medicine. 

Potassium  acetate,  KCgHgO,. 
Potassium  nitrate,  KNO3. 
Potassium  chlorate.  KCIO3. 

What  is  methylic  alcohol?  What  are  its  properties  and 
uses? 

Methylic  or  wood  alcohol.  CH,OH,  is  obtained  as  a  product 


CHEMISTRY.  127 

of  the  destructive  distillation  of  wood.  It  is  a  light,  colorless 
liquid,  miscible  with  water,  inflammable,  burning  with  a  non- 
luminous  flame. 

It  has  a  large  use  in  the  arte  as  a  solvent  for  resinous  and 
gum-like  substances,  as  in  the  making  of  varnishes;  and  is 
used  as  a  fuel. 

Defend  the  statement,  "  Matter  is  indestructible." 

That  matter  is  indestructible  may  be  illustrated  by  the 
burning  of  a  candle,  where  although  the  candle  loses  in  weight 
from  the  consumption  of  its  wax,  yet  if  eare  be  taken  to  save 
and  weigh  the  results  of  the  combustion  it  will  be  found  that 
nothing  has  been  lost,  that  the  burned  substance  has  merely 
assumed  a  different  form. 

Explain  and  illustrate  the  law  of  chemical  combination 
by  volume. 

Law  of  Gay-Lussac :  When  two  or  more  gases  combine 
chemically  to  form  a  gaseous  compound  the  volumes  of  the 
individual  constituents  bear  a  simple  relation  to  the  volume 
of  the  product.  Thus  one  volume  of  hydrogen  combines  with 
one  volume  of  chlorine  to  form  two  volumes  of  hydrochloric 
acid  vapor.  Again,  three  volumes  of  hydrogen  combine  with 
one  volume  of  nitrogen  to  form  two  volumes  of  ammonia. 

Give  the  history,  occurrence  in  nature  and  preparation 
of  oxygen. 

Attention  was  first  called  to  the  existence  of  oxygen  by  Dr. 
John  Mayow,  of  England,  in  1664.  Oxygen  was  discovered  by 
Dr.  Joseph  Priestley,  of  Birmingham,  England,  on  August 
1st.  1774.  It  was  given  the  name  oxygen,  "  acid-producer," 
by  Lavoisier,  the  French  chemist,  because  it  was  believed  to 
be  an  essential  constituent  of  all  acids. 

It  is  found  free  in  air  and  dissolved  in  water.  It  is  found 
in  combination  in  water  and  in  most  animal,  vegetable,  and 
mineral  compound.s.  It  may  be  prepared  by  heating  a  mix- 
ture of  manganese  dioxide  and  potassium  clilorate. 


128  CHEMISTRY. 

Qive  reasons  from  a  chemical  standpoint  for  the  use  of 
gold  and  silver  for  coin. 

They  do  not  oxidize  in  air  or  water;  when  properly  alloyed 
they  are  durable;  their  degree  of  purity  may  be  readily  de- 
termined by  reagents;  they  do  not  communicate  an  odor  or 
a  poisonous  effect  when  handled  and  their  intrinsic  value  is 
fairly  constant. 

Name  three  metals  of  the  alkaline  earths,  giving  a  com= 
pound  of  each  with  its  formula. 

Barium ;  barium  chloride,  BaClg. 
Strontium;  strontium  nitrate,  Sr(N03)2. 
Calcium;  calcium  carbonate,  CaCO,,. 

What  are  the  general  characteristics  of  the  metals  of 
the  iron  group? 

When  at  a  red  heat  they  decompose  water;  their  oxides, 
hydroxides,  phosphates  and  carbonates  are  insoluble  in  water. 
They  have  relatively  high  fusing  points,  and  considerable 
tenacity,  malleability  and  ductility.  They  are  all  precipitated 
when  in  alkaline  solution,  by  hydrogen  sulphide. 

What  is  coaNoil,  and  what  are  some  of  its  principal 
products  used  in  the  practice  of  medicine? 

Coal  oil,  or  petroleum,  is  a  brown-colored  oil  found  in 
nature  and  probably  produced  from  decomposition  of  organic 
matter.  It  is  a  mixture  of  liquid  paraffin  hydrocarbons,  con- 
taining the  gaseous  and  solid  hydrocarbons  in  solution.  Some 
of  the  principal  products  used  in  medicine  are  benzin  or  ben- 
zinum,  petrolatum  liquidum  or  liquid  vaseline,  petrolatum  or 
vaseline,  and  paraffinum  or  paraffin  wax. 

Complete  the  following  equation  and  write  the  name  of 
the  resulting  compounds: 
C.HCI.O  +  KOH= 
C2HCI3O  -f  KOH  =  KCOOH         +         CHCI3 

Potassium  formate.  Chloroform. 


CHEMISTRY.  129 

Give  the  general  properties  of  alkaloids. 

The  alkaloids  may  be  described  as  organic  nitrogenous  sub- 
stances, basic  in  character,  capable  of  combining  directly  with 
acids  to  form  salts.  They  are  commonly  divided  into  two 
groups:  (1)  Liquid  or  Volatile  alkaloids,  containing  carbon, 
hydrogen  and  nitrogen.  (2)  Fixed  or  non-volatile  alkaloids 
containing  carbon,  hydrogen,  nitrogen  and  oxygen.  They 
may  also  be  classified  according  to  origin  as  vegetable,  ani- 
mal, or  synthetic.  The  volatile  alkaloids  are  volatile  liquids 
colorless  when  pure  and  freshly  prepared,  but  turning  brown 
on  exposure  to  the  air.  Examples:  nicotine,  coniine,  spar- 
teine. The  non-volatile  alkaloids  are  crystalline  solids.  Ex- 
amples: morphine,  aconitine,  quinine.  Most  alkaloids  are 
soluble  or  very  slightly  soluble  in  water,  more  soluble  in  al- 
cohol and  in  chloroform  while  the  salts  of  the  alkaloids  are 
generally  soluble  in  water  and  alcohol  and  less  soluble  in 
chloroform. 

What  is  the  percentage  composition  of  NaNOg? 

Atomic  weight  of  Na  is  23;  of  N,  14;  of  0,  16;  of  0^,  48. 
The  molecular  weight,  then,  of  NaNOg  is  85. 

85  :  100 : :  23  :  X  =  sodium,         27.     per  cent. 
85  :  100 : :  14 :  X  =  nitrogen,        16.4 
85:100::48:X  =  oxygen,         56.6 


100.0 


Why  is  capillary  attraction  so  called?  Mention  some 
familiar  examples. 

Because  this  force  is  best  observed  in  liquids  enclosed  in 
minute  tubes,  hair-like  in  size  (Capillus,  hair). 

The  rise  of  oil  in  a  lamp  wick.  The  flow  of  sap  through 
vegetable  fiber.    The  absorption  of  a  liquid  by  blotting-paper. 

Define  sterilization. 

Sterilization  is  the  act  of  rendering  sterile — of  destroying 
germ  life. 
9 


130  CHEMISTRY. 

How  does  permanganate  of  potassium  act  as  a  disin=° 
fectant? 

In  contact  with  organic  matter  it  undergoes  decomposition, 
liberating  its  oxygen  in  a  nascent  form. 

Upon  what  theory  are  eggs  given  in  cases  of  poisoning 
by  corrosive  mercury? 

That  the  albumin  of  the  egg  will  form  an  insoluble  album- 
inate of  mercury. 

Give  the  boiling=point  (Fahrenheit)  of  water,  alcohol,, 
of  ether,  of  mercury. 

Water  boils  at  212°  ;  alcohol  at  173°  ;  ether  at  96°  ;  mer- 
cury at  675°. 

Give  the  names  and  formulas  of  four  iodides  commonly 
used  in  medicine. 

Mercuric  iodide,  or  the  red  iodide  of  mercury,  Hglg ;  potas- 
sium iodide ;  KI ;  sodium  iodide,  Nal ;  strontium  iodide,  Srig. 

Give  the  formula  for  carbolic  acid.  How  is  it  obtained, 
and  what  are  its  properties  and  uses? 

Carbolic  acid,  phenol,  CgHgOH,  produced  in  the  destruc- 
tive distillation  of  coal,  is  obtained  from  coal  tar.  When 
pure  is  a  crystalline  solid  with  a  characteristic  odor,  pun- 
gent and  caustic  taste,  forming  a  white  eschar  on  the  skin. 
The  crystals  require  an  addition  of  but  five  per  cent,  of" 
water  to  liquefy  them ;  if  more  water  be  added  a  turbid  mix- 
ture results,  which  again  becomes  dear  when  20  parts  of 
water  have  been  added.  Carbolic  acid  is  soluble  in  20  parts 
of  water;  easily  soluble  in  alcohol,  glycerin  and  oils.  It  is 
used  as  an  antiseptic,  a  disinfectant  and  a  caustic.  It  has 
slight  local  anesthetic  properties. 

Give  the  comparative  constituents  of  cow's  milk  and 
human  milk  as  relating  to  water,  fat,  sugar,  albuminoids. 

Cow's  milk,  according  to  Frankland,  will  show  on  the  aver- 
age, water  87.5  p.  c,  fat,  3.8  p.  c,  sugar,  3.8  p.  c,  and  al- 
ibuminoids  (proteids),  4.2  p.  c. 


CHEMISTRY.  131 

Woman's  milk  will  show  water,  88.6  p.  c,  fat,  3.5  p.  c, 
sugar,  5.0  p.  c,  and  albuminoids  (proteids),  2.7  p.  c. 

Human  milk  contains,  then,  rather  less  proteid,  more  sugar, 
about  the  same  amount  of  fat,  and  rather  less  water,  than 
cow's  milk. 

How  are  the  compounds  containing  two,  three,  or  four 
elements  distinguished  by  name?     Define  hydroxide. 

Compounds  composed  of  two  elements  are  called  binary 
compounds,  and  their  names,  if  they  are  salts,  end  in  "  ide. " 

Compounds  containing  three  elements  are  tenary  com- 
pounds and,  if  acids,  their  names  terminate  in  "  ic,"  or  in 
"  ous;"  while  if  salts  their  names  end  in  "  ate,"  or  "  ite. " 

Compounds  made  up  of  four  elements  are  called  quater- 
nary compounds. 

A  hydroxide  is  a  compound  of  the  radical  hydroxyl,  OH, 
with  a  metal  or  basic  radical. 

Define  anhydrous,  deliquescent,  electrolysis,  decantation. 

An  anhydrous  substance  is  one  from  which  water  has  been 
removed,  as  anhydrous  sulphate  of  copper. 

A  deliquescent  substance  is  one  which  will  absorb  moisture 
on  exposure  to  air. 

Electrolysis  is  decomposition  of  a  fluid  into  its  constituents 
by  the  action  of  an  electric  current. 

Decantation  refers  to  the  act  of  pouring  off  a  supernatant 
liquid  from  a  precipitate  or  sediment. 

Give  the  reaction  of  tannin  with  (a)  preparations  of 
iron,  (b)  gelatin. 

(a)  A  purplish-black  precipitate  of  a  tannate  of  iron  is 
formed,     (b)  Forms  immediately  a  brownish  precipitate. 

What  relation  does  the  amount  of  solid  matter  in  urine 
bear  to  the  specific  gravity  of  urine? 

The  total  solids  measured  in  grammes,  in  1000  Cc.  of  urine 
are  approximately  equal  to  2.33  (Hasers  coefficient)  times  the 
last  two  figures  of  the  specific  gravity. 


132  CHEMISTRY. 

Give  source  and  characteristics  of  citric  acid. 

Citric  acid,  HgCgHgOT,  HgO,  is  obtained  from  lemons  and 
limes.  Occurs  as  colorless,  rhombic  crystals,  odorless,  acid 
taste,  eflSorescing  in  warm  dry  air  and  deliquescing  in  moist 
air.  Soluble  in  water  and  alcohol,  antiseptic,  antiscorbutic, 
and  refrigerant. 

Give  the  formula,  synonyms  and  properties  of  (a)  mer= 
curous  iodide,  (b)  mercuric  iodide. 

Mercurous  iodide,  Hgglo  or  2HgI,  known  also  as  proto-iodide 
of  mercury,  and  yellow  mercurous  iodide,  is  a  yellow,  odorless, 
tasteless  powder,  almost  insoluble  in  water,  insoluble  in  al- 
cohol, easily  undergoing  decomposition  into  mercuric  iodide 
and  mercury. 

Mercuric  iodide,  bin-iodide  of  mercury,  or  red  mercuric 
iodide,  Hgis,  is  a  scarlet-red,  odorless,  tasteless  powder, 
almost  insoluble  in  water,  slightly  soluble  in  alcohol,  becomes 
yellow  on  heating,  regaining  red  color  when  cooled.  It  is 
poisonous  and  resembles  mercuric  chloride  in  therapeutic 
activity. 

Give  the  formula,  preparation  and  properties  of  nitrate 
of  silver.     Mention  a  test  for  nitrate  of  silver. 

AgNOa,  formed  by  dissolving  silver  in  nitric  acid,  evapor- 
ating the  excess  of  acid,  dissolving  the  residue  in  water  and 
evaporating  to  crystallization.  It  occurs  in  colorless  rhombic 
crystals,  odorless  but  with  caustic,  metallic  taste.  Easily 
soluble  in  water,  less  soluble  in  alcohol.  It  is  a  self-limiting 
caustic,  and  is  employed  internally,  as  an  astringent  and 
alterative.  Test:  A  soluble  chloride  added  to  silver  nitrate 
solution  precipitates  curdy  white  silver  chloride,  soluble  in 
ammonium  hydroxide,  insoluble  in  nitric  acid.  Evaporated 
with  phenolsulphuric  acid  a  pink  coloration,  characteristic  of 
nitrates  is  obtained. 

Mention  the  properties  of  (a)  hydriodic  acid,  (b)  hydro= 
bromic  acid. 

(a)  Hydriodic  acid,  HI,  is  a  fuming,  colorless  gas,  strongly 


CHEMISTRY.  133 

acid,  freely  soluble  in  water  to  form  a  colorless  solution  turn- 
ing brown  from  decomposition  and  separation  of  free  iodine. 
Hydriodic  acid  possesses,  in  less  marked  degree,  the  general 
properties  of  hydrochloric  acid;  its  binary  salts  are  used 
medicinally. 

(b)  Hydrobromic  acid,  HBr,  is  a  colorless  gas  of  acid  na- 
ture, soluble  in  water  forming  a  clear  colorless  liquid  having 
properties  closely  resembling  those  of  hydrochloric  acid — 
its  binary  salts  are  used  in  medicine. 

Give  a  test  for  the  detection  of  alum  in  baking=powder. 

Dissolve  in  25  Cc.  water  and  add  5  Cc.  of  a  5%  solution 
of  ammonium  carbonate.  If  alum  be  present  a  violet  or 
lavender  color  is  produced. 

Give  the  chemical  changes  occurring  when  potassium  is 
placed  on  water. 

Two  atoms  of  potassium  displace  two  atoms  of  hydrogen 
from  a  water  molecule  to  form  K2O  and  this  combines  with 
a  second  water  molecule  to  form  two  molecules  of  potassium 
hydroxide.  The  liberated  hydrogen  takes  fire  from  the  heat 
of  the  chemical  action. 

H2O  +  K2  =  K2O  +  H^. 

K^O  +  H2O  =  2K0H. 

Define  photography. 

It  is  the  art  of  obtaining  in  permanent  form  the  images  of 
the  camera  obscura,  by  causing  light  to  produce  chemical 
changes  on  sensitive  substances. 

Write  the  graphic  formula  of  (a)  sulphuric  acid,  (b) 
nitric  acid,  (c)  calcium  hydrate. 

(a)  pjo>  b  <;<Q 

(b)  HO-N«g 

(c)  HO  — Ca  — OH 


134  CHEMISTRY. 

Describe  the  relations  of  oxygen  to  combustion  and  to 
life. 

Oxygen  is  the  great,  universal  supporter  of  combustion, 
entering  into  chemical  union  with  all  well-known  elements 
(except  fluorine)  often  with  sufficient  energy  to  produce  heat 
and  light  (active  combustion). 

Since  life  is  maintained  only  through  a  constant  oxidation 
of  existing  tissues  (a  form  of  slow  combustion),  and  the  re- 
placement of  these  oxidized  and  decomposed  structures  by  new 
materials,  oxygen  is  essential  to  life. 

^Vhat  mineral  acids  are  incompatible  with  mercurous 
chloride?    Give  synonyms  of  mercurous  chloride. 

Mercurous  chloride,  Hg^CL  or  2HgCl,  known  also  as 
calomel,  mild  mercurous  chloride,  and  proto-chloride  of 
mercury. 

This  substance  is  incompatible  with  sulphurous  acid,  hydro- 
ohloric  acid,  and,  in  general,  ^vith  all  strong  mineral  acids. 

Describe  the  appearance  of  urine  containing  bile. 

Such  urine  varies  in  color  from  greenish-brown  to  a  brown- 
ish-black (porter-colored),  and  produces,  on  shaking,  a  per- 
sistent froth,  yellow  in  color. 

Define  decomposition,  putrefaction. 

Decomposition  refers  to  the  breaking  up  of  a  complex  or 
compound  substance  into  simpler  substances. 

Putrefaction  is  the  decomposition  of  a  nitrogenous  organic 
substance  into  simpler  bodies  by  bacterial  action. 

Give  the  general  definition  of  an  ether. 

An  ether  is  an  oxide  of  a  hydrocarbon  radical. 

Give  a  test  for  the  detection  of  hydrocyanic  acid  in 
solution.  ' 

Silver  nitrate  produces  a  curdy  white  precipitate  of  silver 
cyanide,  soluble  in  ammonium  hydroxide,  and  in  strong  boil- 
ing nitric  acid. 


CHEMISTRY.  135 

Complete  the  following  equations: 
CH3CI  +  HCl  +  Zn  = 
2FeCl3  +  H2S  = 

CH3CI  +  HCl  +  Zn  =  CH,  +  Z11CI2. 
2FeCl3  +  H2S  =  2FeCl2  +  2HC1  +  S. 

Give  the  symbol,  valence  and  a  principal  compound  of 
each  of  ten  elements. 

Hydrogen,  symbol  H,  valence  I,  water,  HgO. 

Oxygen,  symbol  0,  valence  II,  nitrous  oxide,  NjO. 

Nitrogen,  symbol  N,  valence  I,  III,  V,  ammonia,  NHj. 

Iodine,  symbol  I,  valence  I,  potassium  iodide,  KI. 

Sulphur,  symbol  S,  valence  II,  IV,  VI,  hydrogen  sulphide, 
HgS. 

Bromine,  symbol  Br,  valence  I,  sodium  bromide,  NaBr. 

Iron,  symbol  Fe,  valence  II,  IV  (FCg  VI),  ferrous  sulphate, 
FeSO,. 

Calcium,  symbol  Ca,  valence  II,  calcium  hydroxide, 
Ca(0H)3. 

Magnesium,  symbol  Mg,  valence  II,  magnesium  carbonate, 
MgC03. 

Silicon,  symbol  Si,  valence  IV,  silicon  oxide,  SiOj. 

State  the  normal  reaction  of  synovial  fluid. 

Alkaline. 

Describe  the  microscopic  appearance  of  (a)  uric  acid, 
(b)  triple  phosphates. 

(a)  Yellow  to  orange-red  in  color,  losenge-shaped,  rhombic 
■prisms  or  modified  forms,  often  grouped  in  star-shaped,  or 
fan-shaped  clusters,  sharply  pointed  at  angles. 

(b)  White,  triangular  prisms,  coffin-shaped;  or  in  star- 
shaped,  feathery  crystals. 

Give  a  typical  example  and  state  the  principal  ingre- 
dients of  each  of  the  following  mineral  waters:  Saline 
cathartic,  alkaline,  sulphurous. 

Saline  cathartic  water  may  be   represented   by   Carlsbad 


136  CHEMISTRY. 

mineral  water  containing  sulphates  of  sodium  and  potassium, 
and  carbonates  of  sodium,  calcium  and  iron. 

An  alkaline  mineral  water  as  Buffalo  lithia  water  contains 
carbonates  of  lithium,  calcium,  sodium  and  potassium,  and 
usually  an  excess  of  CO2  although  not  in  sufficient  amount  to 
produce  effervescence. 

A  sulphurous  water,  as  that  of  red  sulphur  spring  of  Vir- 
ginia, usually  contains  hydrogen  sulphide,  or  an  alkaline  poly- 
sulphide. 

Give  the  characteristics  of  (a)  nephritic  urine,  (b)  cys- 
titic  urine. 

In  acute  nephritic  conditions  the  urine  may  be  diminished 
in  amount  with  normal  or  increased  specific  gravity  and  con- 
siderable albumin.  In  chronic  nephritis  the  urine  may  be 
normal  or  increased  in  amount,  the  specific  gravity  low  and 
the  albumin  variable.  Nephritic  urine  always  shows  easts  of 
the  uriniferous  tubules. 

In  acute  cystitis  the  urine  shows  pus,  mucus,  and  epithe- 
lium and  the  reaction  may  be  neutral  or  acid.  In  chronic 
cystitis  the  urine  contains  pus,  mucus,  epithelium  and  separ- 
ated "  triple  phosphates  "  and  the  reaction  is  ammoniaeal. 

Express  the  following  in  apothecaries'  weight  and 
measure: 

Ammonii  carb. 5  grams 

Syr,  aurantii 60  c.  c. 

Aquse  destil.  ad 120  c.  c. 

Ammonii  carb grs.  Ixxvii 

Syr.  aurantii .^  i j 

Aquse  destil.  ad 5  iv 

Complete  the  following  equations: 
C2H5NO3  +  KOH  = 
CaCOa  +  2HCI  = 

C2H5NO3  +  KOH  =  C2H5OH  +  KNO3. 
CaCOa  +  2HC1  =  CaClg  +  H^O  +  CO^. 

Give  the  general  characteristics  of  bismuth. 

Bismuth,    Bi,    atomic    weight,    207    (206.9),    valence    III, 


CHEMISTRY.  137 

specific  gravity  9.9,  melts  512°  F.,  is  a  brittle,  white  metalloid 
with  reddish  tint,  crystalline,  occure  native  and  as  the  sul- 
phide, frequently  associated  ^vith  arsenic. 

Define  and  illustrate  monatomic  element,  neutral   salt. 

A  monatomic  element,  like  mercury,  is  one  whose  molecule 
contains  but  one  atom,  and  whose  molecular  weight  corres- 
ponds with  the  atomic  weight. 

A  neutral  or  normal  salt  is  one  formed  from  an  acid  by 
substituting  a  metal  or  basic  radical  for  all  of  the  replaceable 
hydrogen.  Example:  Sodium  sulphate,  Na2S04,  formed  from 
sulphuric  acid,  H2SO4. 

Indicate  the  sources  of  the  following  acids:  Lactic, 
butyric. 

Lactic  acid  is  developed  from  lactose  in  souring  milk.  It  is 
produced  on  a  large  scale  by  the  lactic  fermentation  of  cane 
sugar  or  glucose. 

Butyric  acid  occurs  in  rancid  butter,  and  cheese.  It  is 
prepared  by  fermenting  a  mixture  of  sugar  and  old  cheese. 

Mention  a  diatomic  element  and  give  its  chemical  prop= 
erties. 

Oxygen,  symbol  0,  atomic  weight  16,  molecular  weight  32, 
valence  II.,  electro-negative,  supporter  of  combustion,  com- 
bines with  all  well-known  elements  except  fluorine. 

Give  an  explanation  of  the  formation  of  ammonia  in  the 
urine. 

Under  the  influehce  of  the  micrococcus  ureae  taken  up  from 
ttie  atmosphere,  the  urea  is  changed  into  ammonium  carbonate. 
CO  (NIT,),  +  2H,0=  (NHJXO3. 

Complete  the  following  equations: 
2FeCl, +  2HCl-fO  = 
2Na,HP0,  -f  3CaCl2  = 

2FeCl2  -f  2IIC1  -h  0  =  Pe^Cle  +  H^O. 

2Na  JIPO,  -f  SCaClj  =  Ca,(P0j2  +  4NaCl  -f  2HC1. 


138  CHEMISTRY. 

Give  the  formula  and  properties  of  (a)  chlorate  of  po= 
tassium,  (b)  ammonia  gas,  (c)  tartaric  acid. 

(a)  Chlorate  of  potassium,  KCIO3,  white  crystalline  solid, 
permanent  in  air,  soluble  in  16.7  parts  of  cold  water  and  1.7 
parts  boiling  water.  A  strong  oxidizing  agent,  decomposable 
by  heat  into  oxygen  and  potassium  chloride,  forms  explosive 
mixtures  when  in  contact  with  strong  acids  or  organic  matter. 
It  is  a  mild  astringent  and  antiseptic. 

(b)  Ammonia  gas,  NH3,  is  a  strongly  basic,  diffusible,  irre- 
spirable  gas,  extremely  light,  and  very  soluble  in  water;  it  is 
colorless,  alkaline  and  caustic  in  taste  and  effect. 

(c)  Tartaric  acid,  H2C4H4O6,  found  in  vegetables  and 
fruits :  in  its  pure  form  occurs  as  colorless,  transparent  prisms, 
strongly  acid  and  readily  soluble  in  water  and  in  alcohol; 
crystals  melt  at  135°  C.  It  forms  salts,  of  which  Rochelle 
salt,  KNaCiH^Og,  cream  of  tartar,  KHC^H^Oe,  and  tartar 
emetic,  KSbOC^H^Og  are  medicinally  useful. 

How  is  anilin  obtained?  State  how  anilin  dyes  are 
manufactured  from  anilin. 

Anilin,  CgHgNHa,  is  obtained  by  the  action  of  nascent  hy- 
drogen on  nitrobenzene. 

Anilin  dyes  are  made  by  oxidizing  mixtures  of  anilin  and 
toluidin  with  nitric  or  chromic  acids  or  other  oxidizing  agents. 

Mention  two  reactions  by  which  hydrocyanic  acid  is 
formed.     Give  the  properties  of  hydrocyanic  acid. 

Add  hydrochloric  acid  to  potassium  cyanide  and  obtain 
potassium  chloride  and  hydrocyanic  acid.  Add  hydrochloric 
acid  to  silver  cyanide  and  obtain  silver  chloride  and  hydro- 
cyanic acid. 

Hydrocyanic  acid  is  a  volatile  colorless  liquid,  with  odor 
of  bitter  almonds.  It  is  extremely  poisonous  and  is  employed 
in  medicine  in  a  2%  water  solution. 

Give   the   symptoms   and   diagnostic   features   of   oxalic 


CHEMISTRY.  139 

acid  poisoning.     With  what  commonly  used  salt  is  oxalic 
acid  likely  to  be  confused? 

Symptoms :  a  hot,  burning,  sour  taste,  burning  sensation 
extending  to  stomach,  great  burning  pain  in  stomach  and  ab- 
domen, prostration,  slight  stupor,  convulsions,  pulse  small 
and  irregular,  numbness  of  extremities,  irregular,  spasmodic 
breathing,  death.  It  acts  as  an  irritant  and  as  a  heart  de- 
pressant. 

Oxalic  acid  has  been  frequently  confused  with  magnesium 
sulphate. 

What  are  aldehydes?  Mention  the  properties  and  prin= 
cipal  derivatives  of  aldehydes. 

Aldehydes  are  substances  formed  by  oxidizing  (taking  two 
hydrogen  atoms  from)  primary  alcohols. 

Aldehydes  combine  directly  with  ammonia,  hydrocyanic 
acid,  alkaline  sulphites,  etc.  They  are  strong  reducing  agents, 
their  oxidation  produces  fatty  acids,  their  reduction  gives  rise 
to  alcohols. 

Formaldehyde  and  paraldehyde  and,  a  derivative,  trichlor- 
aldehyde  or  chloral,  are  all  used  in  medicine.  Derived  from 
chloral  are  many  addition  and  decomposition  products. 

How  are  soaps  made?  What  constitutes  (a)  hard  soap, 
(b)  soft  soap,  (c)  castile  soap? 

By  heating  a  fat,  with  a  strong  alkali,  (a)  Hard  soap  is 
the  sodium  salt  of  a  fat  acid,  (b)  Soft  soap  is  the  potassium 
salt  of  a  fat  acid,  (c)  Castile  soap  is  a  mixture  of  oleate. 
palmitate  and  stearate  of  sodium  obtained  by  saponifying 
olive  oil. 

Complete  the  following  equation: 
KXr„0,  +  4H2SO,  = 

K^Cr^O,  +  4H2SO,  =  Cr^CSOJa  +  K^SO,  -f  4H,0  +0,. 

What  is  an  ion?    Give  an  example  of  ionization. 

When  acids,  bases  and  salts  are  dissolved  in  water  they 
dissociate,     the     Tuolecnles    divide.       Pjach     part     carries    a 


140  CHEMISTRY. 

charge  of  electricity,  and  is  called  an  ion.  Hydrochloric  acid 
dissolved  in  water  dissociates  into  positive  ions  of  hydrogen 
(■cations),  and  negative  ions  of  chlorine  (anions). 

What  simple  tests  should  be  employed  to  determine 
whether  or  not  a  suspected  water  contains  albuminoid 
matters  sufficient  to  make  its  use  unhealthful? 

Add  to  the  water  a  drop  or  two  of  dilute  sulphuric  acid 
and  enough  potassium  permanganate  to  give  a  faint  pink 
color,  cover  the  vessel  with  a  glass  plate  and  if  the  pink  color 
still  persists  after  the  lapse  of  fifteen  minutes  the  water  is 
not  greatly  impure  from  organic  matter. 

Shake  a  stoppered  flask  half  full  of  the  suspected  watery 
if  no  odor  is  discernible,  warm  flask  and  contents  for  fifteen 
minutes  at  a  temperature  not  higher  than  110°  F.  and  after 
again  shaking  vigorously  should  there  still  be  no  odor  the 
water  is  probably  free  of  any  material  quantity  of  dissolved 
organic  matter. 

Mention  the  principal  uses  of  the  following  elements 
and  their  compounds:  (a)  Fluorine,  (b)  chromium,  (c)  sili= 
con,  (d)  selenium. 

(a)  Hydrofluoric  acid  is  used  as  a  solvent  for  glass;  calcium 
fluoride  and  the  double  fluoride  of  sodium  and  aluminum 
are  employed  as  fluxes. 

(b)  Chromium  is  used  in  steel-making;  lead  chromate  and 
barium  chromate  are  used  as  pigments ;  potassium  and  sodium 
dichromate  are  important  reagents;  the  oxides  are  oxidizing 
agents  and  glass  pigments.  The  oxide  CrOg  is  a  powerful 
caustic. 

(c)  Silicon  in  the  form  of  its  oxide  SiOg  is  used  in  making 
glass  and  glass-like  substances ;  hydrofluosilicic  acid  is  a  chem- 
ical reagent;  SiOo  is  also  used  for  polishing,  filtration,  etc. 

(d)  Selenium  is  used,  from  its  non-conducting  property,  in 
certain  electrical  appliances;  selenic  acid,  H2Se04  is  used  as 
a  solvent  for  gold. 


CHEMISTRY.  141 

State  the  atomic  weight,  valence  and  uses  of  sulphur. 

Sulphur,  atomic  weight  32  (31.83),  valence  II,  IV,  VI. 

Is  used  in  making  gun  powder,  matches,  as  a  medicine,  is 
incorporated  into  rubber,  is  burned  to  form  SOg  and  in  this 
combination  used  for  disinfection,  bleaching  and  in  making 
sulphuric  acid.   . 

Complete  the  following  equations: 
BaClo+  Na.SO^^ 
3P  +  5HN0"3  +  2H20  = 

BaCl^  +  NaoSO,  =  BaSO^  +  2NaCl. 

3P  +  5HNO3  +  2H2O  =  3H3PO^  +  5N0. 

Differentiate  arsenic  from  antimony. 

In  Marsh's  test  on  burning  the  evolved  gas  both  arsenic 
and  antimony  produce  brown-black  stains  on  a  piece  of  cold 
porcelain  held  in  the  flame,  but  the  stain  due  to  arsenic  is 
freely  soluble  in  chlorinated  lime  solution  while  the  anti- 
monial  stain  is  almost  insoluble  in  this  reagent.  If  arseni- 
cal and  antimonial  substances  be  strongly  heated  in  air,  arsenic 
forms  octahedral  crystals  of  ASoOg  which  dissolving  in  water 
produce  green  and  yellow  precipitates  respectively  with 
cupric  ammonium  sulphate  and  silver  ammonium  nitrate; 
while  antimony,  oxidizing,  gives  needle-like  crystals  or  an 
amorphous  deposit,  soluble  in  water  but  not  precipitated  by 
the  reagents  named. 

Give  two  chemical  tests  for  blood. 

Add  a  drop  of  suspected  liquid  to  a  freshly-made  tincture 
of  guaiacum,  in  a  test-tube,  then  on  the  surface  of  this  liquid 
float  an  etherial  solution  of  hydrogen  dioxide.  If  the  sus- 
pected liquid  contains  blood,  a  blue  color  band  forms  at  the 
junction  of  the  two  liquids. 

To  a  drop  of  blood  on  a  glass  slide  add  a  drop  or  so  of 
glacial  acetic  acid  and  a  small  crystal  of  sodium  chloride. 
Heat  slowly  to  boiling,  then  cool  and  examine  under  the  mi- 
croscope for  crystals  of  hematin  hydrochloride. 


142  CHEMISTRY. 

Describe  the  tests  for  acetone,  and  for  diacetic  acid  in 
the  urine. 

For  acetone  add  to  the  urine  sufBeient  sodium  hydroxide 
to  give  a  decided  alkaline  reaction  and  then  add  a  few  drops 
of  an  aqueous  solution  of  sodium  nitroprusside.  The  mix- 
ture assumes  a  ruby-red  color.  Acidify  with  galacial  acetie 
acid — a  purple-red  color  indicates  the  presence  of  acetone. 

Test  for  diacetic  acid:  To  a  freshly-passed  specimen  of 
urine  add  a  few  drops  of  a  ferric  chloride  solution ;  if  a  pre- 
cipitate forms,  filter,  and  to  the  filtrate  add  a  few  more  drops 
of  the  reagent.  If  diacetic  acid  be  present  there  is  produced 
a  dark  red  color  which  fades  on  boiling. 

Describe  a  test  for  excess  of  hydrochloric  acid  in  the 
gastric  contents. 

To  100  Cc.  of  filtered  gastric  contents  add  a  few  drops  of 
tropaeolin  indicator  solution,  and  then  titrate  with  J*^  alkali 
solution  until  the  magenta  color  of  the  solution  is  destroyed. 
If  more  than  55  Cc.  of  the  alkali  solution  are  required  to  neu- 
tralize then  the  acid  is  in  excess. 

Define  albumose;  give  a  test  for  detection. 

Albumoses  are  transition  compounds  formed  in  the  conver- 
sion of  albumin  into  peptone.  Albumose  is  precipitated  by 
nitric  acid  in  the  cold,  dissolves  on  heating,  and  is  again  pre- 
cipitated on  cooling. 

Define  bilirubin;  describe  its  properties;  give  test  for 
its  presence. 

Bilirubin,  the  principal  bile  pigment,  CieHigNsOg,  is  a 
reddish-yellow  substance,  derived  from  hematin,  slightly  sol- 
uble in  water,  more  soluble  in  hot  chloroform. 

A  drop  of  the  fluid  is  spread  in  a  thin  film  on  a  porcelain 
plate  and  a  drop  of  yellow  nitric  acid  added.  In  the  pres- 
ence of  bile  pigment  the  drop  of  acid  is  surrounded  by 
colored  rings — green,  blue,  and  reddish-yellow. 


CHEMISTRY.  US 

What  substances  in  the  urine,  other  than  glucose,  may 
produce  the  reaction  of  the  JFehling's  test. 

Glycuronic  acid  gives  the  same  reaction  as  does  glucose. 
Uric  acid,  creatinine,  pyrocatechin,  lactose,  pentose,  chloro- 
form, etc.,  may  produce  partial  reactions. 

Describe  a  chemical  test  that  would  suggest  the  pres= 
ence  or  absence  of  gastric  carcinoma. 

A  marked  diminution  in  or  absence  of  free  hydrochloric 
acid  in  the  gastric  contents  as  shown  by  titration  with  a  ^.^ 
alkali  solution.  Normally  about  55  Cc.  of  Ji^  alkali  are  re- 
quired to  neutralize  100  Cc.  of  gastric  juice. 

<jive  chemical  tests  for  the  various  forms  of  urinary 
calculi. 

A  calculus  which  on  heating  to  redness  burns  entirely  away 
may  be  of  uric  acid,  urate  of  ammonium,  xanthine,  cystin, 
or  fibrin.  Test  a  portion  of  the  powder  with  boiling  water; 
urates  dissolve,  uric  acid  remains  undissolved.  Apply  the 
murexid  test — evaporate  with  nitric  acid  and  touch  the  res- 
idue with  a  drop  of  ammonia  water.  A  purple-red  color  in- 
dicates uric  acid  or  urates. 

If  the  calculus  fuses  when  heated,  giving  off  water  vapor 
and  ammonia,  it  is  a  "  fusible  calculus  "  and  consists  of  a 
mixture  of  calcium,  magnesium,  and  ammonium  phosphates. 

If  the  calculus  leaves  a  residue  when  heated  and  gives  a 
murexid  test  it  consists  of  sodium  urate.  If  it  dissolves  in 
acetic  acid  and  a  precipitate  is  formed  on  adding  ammonia 
water  it  is  a  phosphate  of  calcium  or  magnesium.  If  it  is 
insoluble  in  acetic  acid  but  soluble  in  hydrochloric  acid,  it  is 
calcium  oxalate.  If  on  adding  an  acid  an  effervescence  is 
produced  a  carbonate  is  present. 

Detail  a  test  for  the  detection  of  indoxyl-potassium  sul- 
phate (indican). 

To  5  Cc.  concentrated  fuming  hydrochloric  acid  add  20 
drops  of  urine,  and  warm,  but  do  not  boil,  the  mixture.  With 
normal   urine  the  resulting  color  will  be  yellow  or  a  very 


144  CHEMISTRY. 

pale  violet,  while  with  increased  indican  a  darker  violet  or 
blue  will  be  obtained.  If  the  hydrochloric  acid  is  not  suffi- 
ciently concentrated  add  1  drop  of  nitric  acid  before  adding 
the  urine. 

Give  the  average  chemical  composition  of  human  urine. 

Urea,  urates,  etherial  sulphates,  indican,  etc.  Chlorides, 
sulphates  and  phosphates  of  sodium,  potassium,  calcium,  and 
magnesium,  and  various  pigments. 

Describe  a  method  of  detecting  uric  acid  by  the  use  of 
HNO3. 

Murexid  test :  Evaporate  the  sediment  with  a  drop  of  nitric 
acid.  A  yellow  residue  is  obtained,  which,  when  moisitened 
with  ammonium  hydroxide  turns  to  a  purple-red. 

Give  in  detail  a  test  for  albumin  in  the  urine. 

Float  the  urine  over  pure  concentrated  nitric  acid  in 
a  test-tube.  A  white  ring  or  zone  at  the  contact  of  the  two 
liquids  indicates  albumin. 

What  substances  in  the  urine  other  than  glucose  pre= 
cipitate  hydroxide  of  copper? 

Grlycuronic  acid,  also  lactose,  and,  in  slight  degree,  excess 
of  uric  acid,  hippuric  acid,  creatinine,  xanthine  bases,  etc. 

Describe  a  method  differentiating  albumin  and  mucin. 

Dilute  the  urine  and  add  strong  acetic  acid  drop  by  drop. 
In  presence  of  mucin  a  precipitate  is  formed,  soluble  in  excess 
of  the  acid.  Albumin  does  not  give  this  test  but  is  coagulated 
by  boiling,  while  mucin  is  not. 

Describe  uric  acid  and  a  test  for  its  detection. 

Uric  acid  is  a  crystalline  insoluble  substance  with  the  for- 
mula C5H4N4O3.  It  may  be  found  in  urinary  sediments,  from 
acid  urine,  in  reddish-yellow  crystals,  often  of  whetstone  or 
spear-like  form.  Normally  it  is  present  in  solution  in  the 
urine  in  the  form  of  urates. 

Uric  acid  is  recognized  by  the  murexid  test.  Evaporate  the 
sediment  with  a  drop  of  nitric  acid.     The  yellow  residue  ob- 


o  ^ 


CHEMISTRY.  145 

tained  turns  to  a  purple-red  when  moistened  with  a  drop  of 
ammonium  hydroxide. 

Omitting  albumin  and  glucose  name  three  abnormal 
products  in  the  urine  and  describe  a  chemical  test  for  each. 

Bile;  Test  for  the  bile  pigment  by  Gmelin's  test.  Float  the 
urine  over  yellow  nitric  acid;  a  succession  of  colors,  green, 
blue,  violet  and  red,  will  appear  at  the  contact  of  the  two 
liquids. 

Blood;  Hemin  test.  Place  a  few  drops  of  the  urine  on  a 
glass  slide  and  add  a  drop  or  so  of  glacial  acetic  acid.  Heat 
cautiously  until  bubbles  appear.  On  cooling  there  will  separ- 
ate out  dark-brown  triclinic  plates  and  prisms  of  "  hemin," 
the  hydrochloride  of  hemitin. 

Acetone;  Make  the  urine  alkaline  with  sodium  hydroxide 
and  then  add  a  fresh  solution  of  sodium  nitroprusside.  Acid- 
ify with  strong  acetic  acid — a  purple-red  color  indicates  the 
presence  of  acetone. 

Describe  the  quantitative  estimation  of  urea  in  a  given 
specimen  of  urine. 

Urea  is  generally  detennined  by  the  hypobromite  method. 
A  measured  quantity  of  urine  is  subjected  to  the  action  of  a 
strongly  alkaline  solution  of  sodium  hypobromite.  Nitrogen 
gas  is  set  free,  and  from  the  amount  of  this  gas  the  amount  of 
urea  can  be  obtained — either  by  calculation,  or,  in  certain 
special  instruments,  by  direct  readings  from  the  graduations 
marked. 
10 


ANATOMY. 

What  is  connective  tissue?  Where  in  the  body  is  con^ 
nective  tissue  found? 

Connective,  or  areolar,  tissue  consists  of  branched  cells,  or 
connective  tissue  corpuscles,  the  fibres  of  which  interlace  and 
form  spaces  or  areolae.  It  is  freely  distributed  throughout 
the  body,  forms  sheaths  of  muscles,  blood  vessels,  nerves,  etc., 
binds  parts  together  and  forms  a  generally  evenly  spread-out 
layer  beneath  the  skin,  the  superficial  fascia. 

Into  what  and  how  far  from  the  pyloric  orifice  of  the 
stomach  does  the  ductus  communis  choledochus  normally 
open? 

Into  the  duodenum  upon  its  concave  side  (descending  por- 
tion) three  or  four  inches  below  the  pyloric  orifice. 

Give  the  course,  relations  and  structure  of  the  ureter. 

Begins  in  the  upper  expanded  portion,  the  "pelvis  of  the 
kidney,"  passes  downward  behind  the  peritoneum  upon  the 
psoas  magnus  muscle,  over  the  brim  of  the  pelvis  into  pelvic 
cavity,  forward  to  base  of  bladder,  between  rectum  and  blad- 
der in  male,  l^  inch  from  cervix  in  female,  then  between 
vagina  and  bladder,  terminating  at  posterior  angle  of  trigone. 
It  consist  of  three  coats,  fibrous,  muscular  and  mucous. 

What  constitutes  the  brachial  plexus? 

The  5th,  6th,  7th  and  8th  cervical  nerves  and  1st  thoracic 
nerve. 

Mention  the  ligaments,  fissures  and  lobes  of  the  liver. 

Tjigainents  are  five  in  number,  falciform  (suspensory), 
round,  coronary,  right  and  left  lateral;  fissures  are  five  in 

(147) 


in> 


148  ANATOMY. 

number,  fissure  for  round  ligament  (obliterated  umbilical 
vein) ,  for  gall-bladder,  for  ductus  venosus,  for  inferior  cava, 
and  transverse  fissure;  lobes  are  five  in  number,  right,  left, 
quadrate.  Spigelian,  caudate. 

Mention  the  abdominal  muscles.  Describe  any  one  of 
these  muscles. 

External  and  internal  oblique,  transversalis,  recti,  pyra- 
midales.  (Quadratus  lumborum,  psoas  magnus  and  parvus, 
and  iliacus  might  be  included.)  Internal  oblique  takes  origin 
from  outer  half  of  Poupart's  ligament,  from  anterior  two- 
thirds  of  middle  lip  of  iliac  crest,  from  lumbar  aponeurosis, 
from  last  three  ribs;  is  inserted  into  linea  alba  and  inner 
extremity  of  ilio-pectineal  line  behind  Gimbernat's  ligament. 
Its  aponeurosis  divides  to  form  sheath  of  rectus  for  its  upper 
three-fourths,  passing  in  front  of  rectus  for  its  lower  fourth. 
The  line  of  this  division  of  internal  oblique  is  called  linea 
semilunaris ;  internal  oblique  unites  with  transversalis  to  form 
conjoined  tendon.  Action  is  to  flex  thorax  upon  pelvis,  or 
vice  versa,  to  rotate  trunk  toward  same  side,  and  to  compress 
abdominal  viscera. 

Locate  the  principal  groups  of  lymphatic  glands. 

Inguinal  (superior  and  inferior),  axillary  and  cervical 
(superficial  and  deep). 

Give  the  anatomy  of  the  true  vocal  chords. 

Are  two  in  number,  formed  by  crico-thyroid  membrane, 
attached  to  retiring  angle  of  thyroid  cartilage  anteriorly  and 
to  vocal  process  of  arytenoid  cartilage  posteriorly;  have 
thyro-arytenoid  muscle  along  their  outer  side.  They  are 
covered  by  mucous  membrane,  which  is  closely  attached  and 
thin,  and  consisting  of  stratified,  squamous  epithelial  cells. 

Give  the  point  of  opening  of  the  parotid  duct,  of  the 
submaxillary  duct  and  of  the  sublingual  duct. 

Parotid  duct,  in  cheek  wall  opposite  middle  upper  molar 
tooth;  of  submaxillary  duct,  in  fraenum  linguae;  sublingual 
duct,  close  to  frgenum  linguae. 


ANATOMY.  149 

Describe  the  ischiorectal  fossae  and  their  contents. 

Are  located  between  the  lower  part  of  the  rectum  and  the 
ischial  tuberosities;  are  triangular  in  shape,  bounded  inter- 
nally by  sphincter  ani,  levator  ani  and  coceygeus  muscles; 
externally  by  tuberosity  of  ischium;  are  filled  with  adipose 
tissue;  in  outer  -wall  is  internal  pudic  artery;  crossing  the 
space  are  inferior  hemorrhoidal  vessels  and  nerves. 

State  origin,  course,  and  distribution  of  sixth  cranial 
nerve. 

Superficial  origin,  from  groove  between  medulla  and  pons; 
course,  forward  through  cavernous  sinus,  exit  from  cranial 
cavity  by  sphenoidal  fissure;  distribution  to  external  rectus 
of  eye. 

Give  the  relations  of  the  right  kidney. 

Rests  upon  quadratus  lumborum  and  psoas  magnus  muscles, 
is  in  contact  with  under  surface  of  right  lobe  of  liver,  has 
duodenum  and  ascending  colon  in  front. 

Describe  the  right  ventricle  of  the  heart. 

Is  placed  mostly  upon  anterior  aspect  of  heart,  does  not 
extend  to  apex,  is  crescentic  in  cross-section,  contains  tricuspid 
valve,  which  guards  right  auriculo-ventricular  opening,  to 
left  and  front  of  which  is  conus  arteriosus  leading  up  to  pul- 
monary orifice,  which  is  guarded  by  pulmonary  semilunar 
valves,  contains  columnae  carneae,  musculi  papillares  and 
chordae  tendineae. 

Describe  endothelium. 

Irregular,  flattened  (squamous)  cells,  attached  edge  to  edge, 
resting  on  basement  membrane. 

Describe  the  external  carotid  artery. 

One  of  the  two  terminal  branches  of  common  carotid,  given 
off  at  level  of  upper  border  of  thyroid  cartilage,  extends  up 
neck,  passes  into  parotid  gland,  where  it  terminates  by  divid- 
ing into  superficial  temporal  and  internal  maxillary  arteries. 
Branches    are:    Ascending    pharyngeal,    to    lateral    wall    of 


150  ANATOMY. 

pharynx ;  superior  thyroid,  to  larynx  and  thyroid  body ;  lin- 
gnal,  to  tongue ;  facial,  to  superficial  parts  of  face ;  occipital, 
to  post-cervical  and  occipital  regions;  posterior  auricular,  to 
external  ajid  middle  ear ;  superficial  temporal,  to  scalp ;  in- 
ternal maxillary,  to  deep  parts  of  face  and,  by  middle  menin- 
geal (through  foramen  spinosum  of  sphenoid),  to  inner  skull 
wall  and  dura. 

What  muscles  form  the  calf  of  the  leg?  Describe  any 
one  of  these  muscles. 

Grastrocnemius  and  soleus.  Gastrocnemius  takes  origin  by 
two  heads  from  internal  and  external  condylar  ridges  of 
femur;  these  heads  unite,  join  the  soleus,  thus  forming  the 
tendo  Achillis,  which  is  inserted  into  the  posterior  extremity 
of  the  OS  calcis. 

Describe  the  thyroid  gland. 

It  consists  of  right  and  left  lobes  connected  by  an  isthmus 
across  2d,  3d  and  4th  rings  of  trachea;  has  a  capsule  and 
trabeculae  enclosing  closed  follicles,  which  contain  colloid 
material. 

Give  a  comprehensive  description  of  any  one  of  the 
long  bones  of  the  body. 

The  humerus  possesses  a  shaft  and  two  extremities.  The 
upper  end  has  a  head  which  is  hemispherical  and  articulates 
with  glenoid  cavity  of  scapula.  Just  below  it  is  the  anatom- 
ical neck,  to  which  the  capsule  of  the  shoulder- joint  is  at- 
tached. Then  come  the  greater  and  lesser  tuberosities,  serving 
for  the  attachment  of  muscles,  while  below  them  is  the  surgical 
neck.  The  bicipital  groove  and  ridges  extend  downward 
between  the  two  tuberosities,  and  also  serve  for  the  insertion 
of  muscles.  Upon  the  posterior  surface  of  the  shaft  is  the 
musculo-spiral  groove.  Rough  impressions  are  found  upon 
the  outer  and  inner  aspects  of  the  shaft  for  the  deltoid  and 
coraco-brachialis  muscles  respectively.  The  lower  end  is  ex- 
panded laterally,  to  receive  the  radius  and  ulna,  and  supports 
the  outer  and  inner  condjdes.     The  articular  surface  is  di- 


ANATOMY.  151 

vided  into  a  capitelluni  externally  for  the  head  of  the  radius, 
and  a  trochlea  internally  for  the  greater  sigmoid  cavity  of 
the  ulna.  Above  the  trochlear  surface  is  the  coronoid  fossa 
anteriorly,  and  the  olecranon  fossa  posteriori}-. 

Into  what  two  great  classes  are  muscles  divided?    Give 
^  macroscopic  and  a  microscopic  description  of  each. 

Voluntary  and  involuntary'.  The  voluntary  muscles  num- 
ber about  311  in  the  body.  The  fibres  are  bound  into  bundles 
by  connective  tissue  (perimysium),  and  are  attached  to  bones, 
ligaments  or  integument  bj-  bands  of  white  fibrous  tissue 
called  tendons.  The  involuntary  muscular  tissue  is  found 
throughout  the  greater  part  of  the  wall  of  the  alimentary 
tract,  in  the  walls  of  the  arteries  and  veins,  and  in  the  uterus. 
The  miscroscopic  appearance  of  a  voluntary  fibre  is  one  that 
is  transversely  striated,  with  a  sarcolemma  (sheath)  inclosing 
the  sarcous  elements.  The  involuntary  fibre  is  fusiform,  is 
longitudinally  striated,  and  possesses  a  centrally  placed 
nucleus. 

Describe  the  right  and  the  left  subclavian  vein. 

The  right  subclavian  vein  rests  on  the  first  rib  in  front  of 
the  scalenus  anticus  muscle,  and  is  a  continuation  of  the 
axillary  vein;  just  below  and  behind  the  sterno-clavicular 
.joint  it  unites  with  the  internal  jugular  vein  to  form  the  right 
innominate  vein.  The  left  subclavian  vein  does  not  differ 
materially  from  the  right;  at  the  junction  of  subclavian  and 
internal  jugular  on  the  left  side  the  thoracic  duct  terminates. 
The  subclavian  veins  receive  the  blood  from  the  upper  ex- 
tremities, shoulders,  chest  wall  and  superficial  area  of  face 
and  neck. 

Mention  the  flexor  muscles  of  the  forearm  and  describe 
one  of  them. 

Flexor  carpi  radialis,  flexor  carj)!  ulnaris,  flexor  sublimis 
digitorum,  flexor  profundus  digitorum,  flexor  longus  pollicis. 
Flexor  profundus  digitorum  takes  origin  from  upper  %  of 
shaft  of  ulna,  from  coronoid  process  and  from  interosseous 


# 


152  ANATOMY. 


membrane ;  is  inserted  by  four  tendons  into  last  phalanx  of 
each  finger;  action,  to  flex  last  phalanx. 

Compare  aponeuroses  with  tendons. 

Aponeuroses  are  broad,  flat  sheets  of  fibrous  tissue  to  which 
muscular  fibres  are  attached,  serving  as  tendons  of  insertion 
for  these  fibres.  Tendons  are  rounded  (cord-like)  or  narrow 
(ribbon-like)  bundles  of  fibrous  tissue  attaching  muscles  to 
bones  or  forming  ligaments  of  joints  (shoulder,  hip). 

Give  the  number  of  the  cervical  vertebrae  and  mention 
the  marked  characteristics  of  such  of  these  vertebrae  as 
are  in  any  way  peculiar. 

Seven.  The  atlas  is  a  ring  with  two  lateral  masses  sup- 
porting a  superior  and  an  inferior  pair  of  articular  processes ; 
it  has  no  spinous  process;  the  axis  has  an  odontoid  process 
on  the  upper  surface  of  its  body ;  the  7th  vertebra  has  a  long 
spine,  hence  its  name,  the  vertebra  prominens. 

Name  the  bones  of  the  head. 

Occipital,  2  parietals,  frontal,  2  temporals,  sphenoid,  eth- 
moid, 2  nasal,  2  lachrymal,  2  inferior  turbinals,  vomer,  2 
raaxillse,  2  palate,  2  malar,  mandible. 

Describe  the  acetabulum. 

Is  formed  by  union  of  ilium,  ischium  and  os  pubis;  has 
horseshoe-shaped  articular  surface  and  non-articular  depres- 
sion at  bottom ;  cotyloid  notch  is  below  and  in  front ;  is  deep- 
ened by  cotyloid  ligament  attached  to  rim. 

Name  the  seven  muscles  of  the  orbit. 

Levator  palpebrae  superioris,  superior,  inferior,  external, 
internal  recti,  superior  and  inferior  oblique. 

Where  is  the  compressor  urethrae  muscle? 

Between  the  two  layers  of  triangular  ligament  and  sur- 
rounds membranous  urethra. 

Describe  the  origin  and  distribution  of  the  optic  nerves. 

They  arise  from  the  optic  commissure,  pass  out  of  cranial 


ANATOMY.  153 

cavity  with  ophthalmic  artery  through  optic  foramen,  pierce 
sclerotic  and  choroid  coats  of  eyeball  to  nasal  side  of  posterior 
pole  and  are  distributed  to  retinae. 

What  is  the  solar  plexus? 

A  neuro-ganglionic  collar  of  the  sympathetic  nervous  system 
surrounding  celiac  axis,  from  which  nerve  trunks  accompany 
arterial  branches  to  supply  all  abdominal  viscera. 

Name  the  foramina  at  the  base  of  the  skull,  and  the 
structures  transmitted  through  each. 

Foramen  magnum :  Spinal  cord,  meninges,  spinal  accessory 
nerves,  vertebral  arteries.  Posterior  condyloid  (inconstant)  : 
Veins.  Anterior  condyloid  (2)  :  Hypoglossal  nerves.  Mas- 
toid: Emissary  vein.  Internal  auditory  meatus:  Auditory 
and  facial  nerves,  auditory  artery.  Jugular  foramen :  Lateral 
and  inferior  petrosal  sinuses,  glosso-pharyngeal,  pneumogas- 
tric  and  spinal  accessory  nerves.  Hiatus  Fallopii:  Great 
superficial  petrosal  nerve.  Middle  lacerated  foramen:  In- 
ternal carotid  artery,  sympathetic  plexus.  Foramen  spino- 
sum :  Middle  meningeal  artery.  Foramen  ovale :  Mandibular 
division  of  sensory  root  of  fifth  cranial  nerve  and  motor  root 
of  fifth.  Foramen  rotundum :  Maxillary  division  of  fifth. 
Vidian  canal :  Vidian  nerve.  Optic  foramen :  Optic  nerve 
and  ophthalmic  artery.  Sphenoidal  fissure:  Motor  oculi, 
trochlear  and  abducens  nerves,  ophthalmic  division  of  fifth, 
ophthalmic  vein.     Olfactory  foramina  :  Olfactory  nerves. 

Describe  the  female  urethra  as  to  (a)  location,  (b) 
dimensions,  (c)  structure. 

Is  located  anterior  to  vagina,  extending  from  internal  uri- 
nary meatus  (neck  of  bladder)  to  external  urinary  meatus 
in  vestibule,  close  to  anterior  margin  of  vaginal  orifice.  It 
is  11/^  inches  long  and  quite  dilatable.  Is  lined  with  mucous 
membrane  (squamous  epithelium,  stratified)  which  is  thrown 
into  longitudinal  folds,  and  is  surrounded  by  an  areolar  coat 
and  by  muscular  layers  containing  inner  longitudinal  and 


154  ANATOMY. 

outer  circular  fi'bres,   with  an  abundance   of  yellow   elastic 
tissue  and  many  vessels,  especially  veins. 

What  is  contained  in  the  right  hypochondriac  region? 

Part  of  right  lobe  of  liver,  part  of  gall-bladder,  part  of 
ascending  colon,  hepatic  flexure,  part  of  right  kidney. 

What  muscles  form  the  tendo  Achillis,  and  where  is  the 
tendon  inserted? 

Gastrocnemius  and  soleus ;  inserted  into  posterior  part  of 
OS  'calcis. 

What  forms  the  internal  malleolus  of  the  ankle=joint? 

The  lower  end  of  the  tibia. 

Describe  the  bones  of  the  foot,  giving  their  divisions 
and  articulations. 

Tarsus  consists  of  os  calcis,  astragalus,  cuboid,  scaphoid, 
cuneiform  bones  (internal,  middle  and  external)  ;  metatarsus 
consists  of  five  bones;  phalanges  number  fourteen.  Astra- 
gulus  ariculates  with  tibia,  fibula,  os  calcis,  scaphoid.  Os 
calcis  articulates  with  astragalus,  cuboid.  Scaphoid  articu- 
lates with  astragalus  and  three  cuneiform  bones.  Cuneiform 
bones  articulate  with  scaphoid  behind,  with  each  other  lat- 
erally, and  with  first,  second,  third  and  fourth  metatarsal 
bones  in  front.  Metatarsals  articulate  with  three  cuneiform 
and  cuboid  behind,  with  each  other,  and  with  first  phalanges. 
Phalanges  articulate  with  metatarsals  and  with  each  other. 

Name  the  articulations  of  the  occipital  bone. 

Atlas,  two  parietals,  two  temporals,  sphenoid. 

What  are  the  special  characteristics  of  the  left  ven= 
tricle  of  the  heart? 

It  forms  the  apex  of  the  heart ;  its  wall  is  thicker  than  that 
of  the  right  ventricle;  its  musculi  papillares  are  fewer  in 
number  and  larger;  auriculo- ventricular  valve  (mitral)  is 
made  up  of  two  segments. 


ANATOMY.  155 

Describe  the  auditory  apparatus. 

Consists  of  three  divisions,  viz.,  external,  middle  and  in- 
ternal ear.  Auricle  is  attached  to  temporal  bone,  is  made 
up  of  elastic  cartilage,  leads  into  external  auditory  meatus, 
at  bottom  of  which  is  obliquely  placed  membrana  tympani. 
Middle  ear  is  narrow  cavity  in  petrous  bone.  Eustachian 
tube  connecting  it  with  the  naso-pharynx ;  mastoid  antrum 
is  in  upper  posterior  part,  leading  into  mastoid  cells;  it  is 
lined  with  mucous  membrane.  The  internal  ear  consists  of 
osseous  labyrinth  containing  membranous  labyrinth,  and  is 
made  up  of  vestibule,  cochlea  and  three  semicircular  canals. 
To  mem'branous  labyrinth  auditory  nerve  is  distributed. 

Mention  the  sutures  at  the  vertex  of  the  skull  and  state 
what  bones  they  unite. 

Sagittal  suture,  uniting  the  two  parietal  bones;  lambdoid, 
uniting  occipital  with  both  parietals;  coronal,  uniting  both 
parietals  behind  with  frontal  anteriorly. 

Mention  and  describe  the  salivary  glands. 

Parotid,  submaxillar}',  sublingual.  Parotid,  largest,  placed 
in  front  of  ear,  behind  ramus  of  mandible;  duet  (Steno's) 
passes  across  masseter  muscle,  perforates  buccinator  muscle, 
terminates  in  cheek  wall  opposite  upper  middle  molar.  Par- 
otid has  facial  nerve,  external  carotid  artery,  t-emporo-maxil- 
lary  vein  passing  through  it. 

Submaxillary  gland  is  located  upon  inner  side  of  body  of 
mandible  posteriorly,  is  crossed  by  facial  artery;  duct  (Whar- 
ton's) pas.ses  forward,  terminating  close  to  frrcnum  linguae. 

Sublingual  gland,  located  in  shallow  fossa  upon  inner  side 
of  body  of  mandible,  near  symphysis,  is  covered  by  mucous 
membrane  of  mouth:  ducts  (Bartholin's)  terminate  near 
fraMiuni  lingua'. 

Mention  any  one  muscle  which  moves  the  humerus  (a) 
forward,  (b)  backward,  (c)  inward. 

(a)  Coraco-brachialis ;  (b)  posterior  fibres  of  deltoid;  (c) 
lati.ssimus  dorsi. 


156  ANATOMY. 

What  would  be  the  collateral  circulation  if  the  brachial 
artery  were  ligated  below  its  profounda  branches? 

Superior  and  inferior  profunda  above,  anastomotica  magna, 
radial  and  ulnar  (anterior  and  posterior)  recurrent  below. 

Describe  the  Meibomian  glands. 

Sebaceous  glands  embedded  in  posterior  surface  of  tarsal 
plates  of  eyelids,  consisting  of  single  duct  with  closely  at- 
tached acini,  orifices  of  ducts  terminating  in  single  row  of 
apertures  along  posterior  lid-margin. 

Give  location  and  a  description  of  the  tubercula  quad=> 
rigemina. 

Located  upon  upper  surface  of  crura  cerebri,  just  behind 
third  ventricle  and  beneath  posterior  part  of  velum  inter- 
positum;  nates  anterior  to  testes.  They  consist  of  gray  mat- 
ter externally,  white  internally,  and  are  connected  with  bra- 
chia  of  optic  tracts. 

Describe  the  renal   blood  circulation. 

Arterial  blood  enters  sinus  through  hilum  by  means  of  renal 
artery,  branches  of  which  pass  between  Malpighian  pyramids 
to  cortico-medullary  junction,  where  they  form  transverse 
branches  which  send  arterioles  into  cortical  and  medullary 
portions  of  kidney,  forming  glomeruli  in  the  former,  and 
plexues  around  the  uriniferous  tubules  in  the  latter.  The 
veins  collect  the  blood  from  these  parts,  form  cortico-medul- 
lary branches  and  pass  through  medullary  portion  between 
pyramids,  leaving  kidney  through  sinus  as  renal  vein. 

Mention  the  muscles  attached  to  the  great  trochanter 
of  the  femur. 

Gluteus  medius  and  minimus,  pyriformis,  obturator  inter- 
nus,  gemellus  superior  and  inferior,  obturator  externus. 

What  arteries,  muscles  and  nerves  would  be  severed  in 
a  cross=section  at  the  middle  of  the  humerus? 

Brachial,  superior  and  inferior  profunda;  biceps,  triceps^ 


ANATOMY.  157 

insertions  of  deltoid  and  coraeo-braehialis,  origin  of  braehi- 
alis  anticus;  museulo-cutaneous,  internal  cutaneous,  median, 
ulnar,  museulo-spiral. 

Describe  the  vagina. 

Begins  at  vulvar  aperture,  extends  upward  and  backward 
in  axis  of  outlet  of  pelvis,  surrounds  cervix  uteri,  reaching 
higher  up  on  cervix  posteriorly  than  anteriorly,  is  lined  with 
laminated  squamous  cells,  has  large  venous  plexuses  in  sub- 
mucosa,  contains  circular  (within)  and  longitudinal  (with- 
out) involuntary  muscle  fibres.  Bladder  and  urethra  are  in 
front,  rectum  is  behind.  Peritoneum  covers  upper  posterior 
wall. 

Differentiate  synarthrosis,  amphiarthrosis,  and  diarth= 
rosis,  giving  an  example  of  each. 

Synarthrosis  is  an  immovable  joint  consisting  of  two  bones 
placed  edge  to  edge  with  little  or  no  fibrous  tissue  intervening; 
example,  lambdoid  suture.  Amphiarthrosis  is  joint  permit- 
ting of  slight  motion,  made  up  of  two  bones  with  intervening 
fibro-cartilaginous  plate  or  disk  and  held  together  by  liga- 
ments; example,  joints  formed  by  bodies  of  vertebrae  and 
intervertebral  disks.  Diarthrosis  is  freely  movable  joint, 
consisting  of  two  or  more  bones  with  articular  surfaces  cov- 
ered with  hyaline  cartilage  and  surrounded  by  ligaments  lined 
with  synovial  membrane ;  example,  hip-joint. 

Describe  the  shouIder»joint. 

Variety,  enarthrodial  (ball-and-socket)  ;  bones,  glenoid 
fossa  of  scapula,  head  of  humerus ;  ligament,  capsular,  which 
is  intimately  blended  with  tendons  of  insertion  of  sub-scapu- 
laris,  supra.spinatus,  infraspinatus  and  teres  minor  muscles; 
tendon  of  long  head  of  biceps  passes  within  eapsule  over 
head  of  humerus,  and  is  surrounded  by  synovial  membrane; 
movements,  flexion,  extension,  abduction,  adduction,  rotation 
and  circumduction. 

Give  the  origin,   insertion,  action   and   nerve   supply  of 


158  ANATOMY. 

any  one  of  the  following  muscles:  superior  oblique,  mas= 
seter,  trapezius. 

Trapezius,  origin  from  external  occipital  protuberance, 
inner  third  of  superior  curved  line  of  occipital  'bone,  liga- 
mentum  nuchae,  spine  of  seventh  cervical  vertebra,  spines  of 
all  thoracic  vertC'brge;  insertion  into  posterior  border,  outer 
third  of  clavicle,  inner  margin  of  acromion  and  entire  upper 
border  of  spine  of  scapula ;  action,  to  retract  head,  to  approxi- 
mate scapulae,  to  elevate  point  of  shoulder,  to  assist  serratus 
magnus  in  rotating  scapula,  as  in  act  of  carrying  arm  to  up- 
right vertical  position ;  nerves,  spinal  accessory,  third  and 
fourth  cervical. 

Give  the  origin,  main  branches  and  relations  of  any 
one  of  the  following  arteries:  external  carotid,  axillary, 
femoral. 

Axillary  artery  is  continuation  of  subclavian  from  outer 
border  of  1st  rib,  extends  to  lower  border  of  axilla  (teres 
major  muscle)  in  line  indicated  by  ooraco-brachialis  muscle 
(inner  border),  lying  behind  and  a;bove  axillary  vein;  outer 
cord  of  brachial  plexus  is  above  it,  inner  cord  is  below  it, 
posterior  cord  is  behind  it,  median  nerve  lies  upon  it;  pecto- 
ralis  minor  muscle  crosses  it  in  front,  pectoralis  major  is  ante- 
rior to  first  and  third  portions;  branches  are  superior  tho- 
racic, acromial  thoracic,  long  thoracic,  alar  thoracic,  sub- 
scapular, anterior  and  posterior  circumflex. 

Describe  the  course  of  the  nerve  fibres  in  the  optic 
commissure. 

Fibres  upon  its  posterior  surface  (Gudden's  commissure) 
have  nothing  to  do  with  sight,  and  unite  posterior  quadri- 
geminal  bodies  (testes)  ;  middle  fibres  decussate,  those  from 
right  optic  tract  passing  to  left  optic  nerve  and  vice  versa, 
to  terminate  in  nasal  half  of  retina ;  outermost  fibres  of  each 
tract  do  not  descussate,  but  pass  into  optic  nerve  to  be  dis- 
tributed to  temporal  half  of  retina  of  same  side. 


ANATOMY.  159 

Give  the  origin,  course  and  distribution  of  the  great 
sciatic  nerve. 

Origin  from  lower  lumbar  and  upper  sacral  nerves  (sacral 
plexus;  course,  through  great  sacro-seiatic  foramen  below 
pyriformis  muscle,  from  beneath  lower  margin  of  gluteus 
maximus  midway  between  trochanter  major  and  tuber  dsehii, 
resits  upon  abductor  magnus  and  divides  about  middle  of  thigh 
into  internal  and  external  popliteal  nerves;  it  supplies  semi- 
tendinosus,  semimembranosus,  adductor  magnus  and  biceps. 
Internal  popliteal  is  eontinued  dowTi  leg  as  posterior  tibial, 
distributed  to  back  of  leg  and  sole  of  foot;  external  popliteal 
curves  around  below  head  of  fibula  to  front  of  leg,  becoming 
anterior  tibial  to  front  of  leg  and  dorsum  of  foot. 

Describe  the  great  omentum. 

Made  up  of  double  fold  of  peritoneum,  extending  from 
greater  cui-vature  of  stomach  downward  for  variable  distance, 
then  returning,  surrounds  transverse  colon.  It  contains  be- 
tween its  layers  more  or  less  adipose  tissue. 

Give  the  gross  and  the  topographic  anatomy  of  the 
pancreas. 

The  "  abdominal  salivary  gland  "  is  located  in  upper  pos- 
terior part  of  abdomen,  behind  stomach,  in  front  of  vertebral 
column  and  left  kidney,  and  to  right  of  spleen.  Is  elongated, 
soft  in  consistency,  made  up  of  lobules  held  together  by  con- 
nective tissue,  is  pinkish  in  color,  and  is  divided  into  tail, 
b(^)dy  and  head,  the  latter  embraced  by  curve  of  duodenum. 
Is  supplied  by  branches  from  splenic  artery,  which  courses 
along  upper  border.  Its  duct,  extending  throughout  the 
length  of  the  gland,  terminates  with  common  bile  duct  in 
descending  portion  of  duodenum. 

Locate  and  describe  the  pericardium. 

Pibro-sorous  sac  surrounding  heart,  pyramidal,  with  l)ase 
attached  to  central  tendon  of  diaphragm,  apex  corresponding 
to  great  vessels  at  base  of  heart,  and  connected  with  deep 
cervical  fascia  by  fihi-ons  prolongations  upward.     Outer  layer 


160  ANATOMY. 

fibrous,  lined  with  parietal  serous  layer,  which  is  reflected 
upon  heart  and  vessels  at  its  base,  constituting  the  visceral 
layer. 

Describe  and  give  the  anatomical  relation  of  the  ap- 
pendix vermiformis. 

Is  Sy2  to  4^  inches  long,  made  up  of  inner  mucous  coat, 
which  is  thickly  set  with  simple,  tubular  glands  (crypts  of 
Lieberkuhn)  and  covered  with  columnar  epithelium,  beneath 
which  is  a  thick  layer  of  adenoid  tissue,  diffused  and  collected 
into  closed  follicles;  outside  of  mucous  membrane  is  sub- 
mucosa,  with  plexuses  of  vessels  and  nerves;  next  comes 
muscular  layer,  having  thick,  inner  circular  and  thinner, 
outer  longitudinal  layer;  the  peritoneum  surrounds  the  ap- 
pendix and  forms  a  meso-appendix,  usually  extending  along 
one-half  the  length  of  the  organ;  in  this  the  appendicular 
artery  (branch  of  ileo-colic)  courses;  arterial  supply  is  of  the 
€nd-artery  variety;  the  nerves  are  branches  of  the  superior 
mesenteric  plexus  of  the  sympathetic  system.  The  appendix 
is  attached  to  the  cecum,  usually  depending  from  its  inner 
and  posterior  aspect,  not  far  from  ileo-ceeal  junction;  it  may 
extend  in  any  direction.  In  the  female  a  fold  of  peritoneum 
is  continued  from  the  broad  ligament  to  the  meso-appendix 
(appendiculo-ovarian  ligament),  and  conveys  a  branch  of  the 
ovarian  artery. 

Describe  Poupart's  ligament,  naming  its  anatomical  re= 
lations  and  uses  as  a  surgical  guide. 

Is  formed  by  aponeurosis  of  external  oblique  muscle  blend- 
ing with  fascia  lata,  and  extends,  slightly  curved  downward, 
from  anterior  superior  iliac  spine  to  pubic  spine;  a  reflected 
portion,  Gimbemat's  ligament,  is  attached  to  pubic  end  of 
iliopectineal  line,  forming  inner  margin  of  femoral  (crural) 
ring  (neck  of  femoral  hernia).  Beneath  Poupart's  ligament 
external  cutaneous  nerve,  ilio-psoas  muscle,  anterior  crural 
nerve,  femoral  artery  and  vein  are  located;  above  and  to 
outer  side  of  pubic  spine  it  forms  outer  pillar  of  external 
inguinal  ring. 


ANATOMY.  161 

Describe  the  femoral  artery  and  its  branches. 

Begins  as  cantiuiiation  of  external  iliac  beneath  middle  of 
Poupart's  ligament,  extends  downward,  bisecting  Scarpa's 
triangle,  through  Hunter's  canal,  at  lower  end  of  which  it 
becomes  the  popliteal.  Branches  are  superficial  epigastric, 
superfieial  circumflex  iliac,  superficial  and  deep  external 
pudic,  profunda,  anastomotica  magna,  muscular. 

Name  the  principal  lobes  of  the  brain  and  the  fissures 
dividing  them. 

Frontal,  parietal,  temporal,  occipital,  central  (island  of 
Reil).  Fissure  of  Rolando  separates  frontal  from  parietal; 
fissure  of  Silvius  separates  frontal  and  parietal  from  tem- 
poral ;  parieto-occipital  fissure  separates  parietal  from  occip- 
ital; central  lobe  is  found  deeply  placed  in  Sylvian  fissure. 

Name  the  twelve  pairs  of  cranial   nerves. 

Olfactory,  optic,  motor  oculi,  trochlear,  trigeminal,  abdu- 
xiens,  facial,  auditory,  glosso-pharyngeal,  pneumogastric,  spi- 
nal accessory,  hypoglossal. 

Name  the  bones  articulating  with  the  humerus. 

Scapula,  radius,  ulna. 

Describe  the  Eustachian  tubes. 

Two  tubes  connecting  middle-car  with  naso-pliarynx. 
Pharyngeal  orifice  is  usually  vertical  slit  just  alx)ve  floor  of 
navsal  chambei-,  behind  posterioi-  naris.  and  bounded  poste- 
riorly by  "  cushion  '"  of  [)harynx.  Tube  is  foi-med  by  tem- 
poi'al  bone  in  angle  between  s(piaiiious  and  petrous  portions, 
and  by  coiled  plate  of  cartilage  attached  to  v{\^^v  of  bony  part 
of  tube:  is  lined  with  ciliated  colnnuiar  epithelium. 

Describe  the  diaphragm,  its  principal  openings  and 
nerve  supply. 

I)<)iiie-shai)e(l  iiniscle,  origin  from  inner  surface  of  la.st  six 

•costal  cartilages,  posterior  surface  of  ensiform  cartilage,  by 

two  crura  from  bodies  of  lumbar  vertebrae  (2d  to  4th),  from 

liganienta    ai'cuata.    external    and    intei-nal.     Tnsei'tion    into 

11 


162  ANATOMY. 

aponeurotic  central  tendon,  which  consists  of  three  leaflets.. 
Aortic  opening  is  between  crura,  and  transmits  aorta,  thoracic 
duct  and  vena  azygos  major;  esophageal  opening  is  anterior 
and  slightly  to  left  of  vertebral  column,  transmitting  eso- 
phagus and  both  pneumogastric  nerves;  caval  opening  is  in 
right  leaflet  of  central  tendon,  and  to  its  margins  the  outer 
coat  of  inferior  cava  is  attached.  Nerve  supply,  both 
phrenics. 

Describe  the  broad  ligaments  of  the  uterus  and  their 
anatomical   relations. 

Double  folds  of  peritoneum  attached  to  floor  and  lateral 
margins  of  true  pelvis,  covering  uterus  anteriorly  and  pos- 
teriorly, reflected  from  it  to  bladder  in  front  and  to  vagina 
behind.  Between  its  layers  are  found  Fallopian  tubes,  round 
ligaments,  utero-ovarian  ligaments,  uterine  and  ovarian 
arteries  and  veins,  lymphatics,  and  fetal  relics.  The  ovaries 
are  attached  to  it  behind,  near  the  pelvic  brim. 

Describe  the  crystalline  lens,  and  state  what  tissues  are 
in  contact  with  it,  and  how. 

Is  a  transparent,  biconvex  body,  convexity  being  greater 
upon  posterior  surface  than  upon  anterior;  is  contained  in 
capsule,  which  is  elastic;  it  consists  of  lens-fibres,  which  are 
derived  from  epithelial  cells  (ectoderm),  arranged  in  layei-s, 
which  are  of  softer  consistency  near  the  surface  (cortex), 
more  compact  and  dense  at  the  center  (nucleus).  It  is  non- 
vascular in  the  adult,  its  nutrition  being  maintained  by  inter- 
cellular transmission  of  nutritive  fluids.  Its  suspensory  lig- 
ament is  formed  by  hyaloid  membrane  enclosing  the  vitreous, 
and  is  attached  to  lens  capsule.  The  lens  rests  in  patellar 
fossa  of  vitreous,  iris  (pupillary  margin)  rests  upon  its  ante- 
rior surface,  and  ciliary  processes  are  in  relation  with  its 
circular  edge. 

Give  a  brief  description  of  the  membranes  of  the  brain. 

The  dura  lines  the  cranial  cavity,  is  adherent  to  the  vault, 
sides  and  base,  and  sends  processes  between  cerebral  hemis- 


ANATOMY.  163 

pheres  (falx  cerebri),  between  derebriim  and  cerebellum 
(tentorium  cerebelli),  and  between  hemisphere  of  cerebellum 
(falx  cerebelli)  ;.  it  splits  to  form  spaces  for  the  intima  of 
veins,  knowTi  as  venous  sinuses.  The  arachnoid,  between  dura 
and  pia,  is  thin  and  delicate,  and  contains  spaces  for  cerebro- 
spinal fluid,  best  developed  at  base  of  brain.  The  pia  closely 
invests  the  encephalon,  dippin«:  into  fissures  and  sulci,  send- 
injr  arterial  branches  into  cerebral  substance  and  receiving 
veins  from  same,  and  passes  through  transverse  fissure  into 
interior  of  brain,  constituting  velum  interpositum.  and  fur- 
nishing choroid  plexuses  of  ventricles. 

Describe  the  gross  anatomy  of  the  larynx. 

Consists  of  cartilaginous  framework,  ligaments,  muscles, 
and  is  lined  with  mucous  membrane.  Cartilages  are  thyroid, 
cricoid,  two  arytenoids,  two  cornicula  laryngis  and  epiglottis. 
Thyroid  is  shield-shaped,  projects  forward  as  pomum  Adami ; 
cricoid  is  ring-shaped,  is  placed  below  thyroid,  is  broad  pos- 
teriorly and  supports  ar>i^enoids.  one  on  each  side  of  posterior 
quadrilateral  portion.  Epiglottis  is  attached  by  stem  to  angle 
of  thyroid,  and  is  directed  upward  over  entrance  to  larnyx. 
Crico-thyroid  membrane  extends  from  cricoid  cartilage  up- 
ward within  thyroid,  and  by  rounded,  free  edge  forms  true 
vocal  bands,  which  extend  between  thyroid  anteriorly  and 
vocal  processes  of  arytenoids  posteriorly.  Lateral  crico- 
arytenoid muscles  approximate  vocal  bands,  posterior  crico- 
arytenoid muscles  separate  them.  Superior  laryngeal  artery 
pierces  thyro-hyoid  membrane  to  supply  interior  of  larynx, 
superior  laryngeal  ner\'e  is  uei-ve  of  sensation  to  mucous 
membrane,  and  recurrent  laryngeal  is  motor  nerve  to  all  mus- 
cles but  one  ( crico-thyroid  1  supplied  by  superior  laryngeal. 

Minutely  describe  the  relations  of  the  peritoneum  to 
the  bladder. 

Covers  upper  surface  and  sides,  reflected  on  to  rectum  in 
male  and  vagina  in  female;  leaves  anterior  abdominal  wall 
just  above  symphysis  to  form  loose  fold  between  bladder  and 


164  ANATOMY. 

symphysis,  then  passing  to  summit  of  bladder  without  cover- 
ing its  anterior  wall,  thus  forming  prevesical  space  (space  of 
Retzius) . 

Describe  the  endocardium. 

Is  continuous  with  the  tunica  intima  of  the  vessels  at  the 
base  of  the  heart,  lines  both  auricles  and  both  ventricles,  and 
forms,  strengthened  by  fibrous  tissue,  the  several  valves  of 
the  heart. 

What  parts  of  the  brain  does  the  Pons  Varolii  connect? 

Cerebellum  wuth  posterior  quadrigeminal  bodies  (testes), 
one  cerebellar  hemisphere  with  the  other,  parts  below  (cord 
and  medulla)  with  cerebral  hemisphere  above. 

Name  the  ganglia  connected  with  the  5th  pair  of  cranial 
nerves. 

Gasserian.  opthalmic,  .spheno-palatine  (Meckel's),  otic, 
submaxillary. 

Give  an  anatomical  description  of  the  bronchial  tubes. 

Formed  by  division  of  trachea;  right  and  left  bronchial 
tubes  pass  into  right  and  left  lungs  respectively  at  root  of 
lung,  dividing  and  subdividing,  finally  becoming  bronchioles. 
Each  consists  of  rings  or  plates  of  cartilage  held  together  by 
an  elastic  membrane,  and  are  lined  by  mucous  membrane 
possessing  ciliated  columnar  epithelial  cells  in  larger  tubes 
and  squamous  cells  in  smallest  tubes. 

Name  the  branches  of  the  subclavian  artery. 

Vertebral,  internal  mammary,  thyroid  axis  (inferior  thy- 
roid, transverse  cervical,  suprascapidar) .  superior  intercostal. 

Describe  the  inguinal  canal. 

Is  a  flat-sided  passage  in  the  lower  part  of  the  inguinal 
region,  extending  between  internal  and  external  abdominal 
rings;  its,"  floor  "  is  formed  by  transversalis  fascia  meeting 
Poupart's  ligament;  its  "  roof  "  by  conjoined  tendon  (inter- 
nal oblique  and  traaasversalis  muscles)  ;  interior  wall  by  skin, 


ANATOMY.  165 

superficial  fascia,  aponeurosis  of  external  oblique,  internal 
oblique ;  posterior  Avail  by  transversalis  fascia,  pre-peritoneal 
fat  and  peritoneum.  Is  about  II/2  inches  long  in  adult,  trans- 
mitting spermatic  coi'd  in  male  and  round  ligament  in  female. 

If  the  femeral  artery  were  obstructed  at  the  apex  of 
Scarpa's  triangle,  through  what  channels  would  the  blood 
flow  to  reach  the  tibial  artery? 

Tlirough  profunda  femoris  and  its  branches,  anastomosing 

with  articular  branches  of    popliteal. 

Name  the  structures  that  maintain  the  bladder  in  posi= 
tion,  male  and  female. 

Recto- vesical  fascia,  folds  of  peritoneum,  in  both  sexes; 
i-ectum  in  male,  uterus  and  vagina  in  female. 

Where  are  the  ventricles  of  the  larynx. 

Between  the  true  and  false  vocal  cords. 

Describe  the  triangle  of  the  elbow  and  name  the  struc= 
tures  that  pass  through  it. 

Base  directed  upward,  formed  by  line  drawn  between  the 
two  condyles,  outer  side  bounded  by  supinator  longus,  inner 
side  by  pronator  radii  teres;  floor  is  formed  by  brachialis 
anticus  and  supinator  brevis.  It  contains  brachial  artery 
and  venai  comites,  radial  and  ulnar  arteries,  median  and 
musculo-spiral  nerves,  and  tendon  of  biceps. 

Name  the  abdominal  viscera  partially  covered  by  peri- 
toneum. 

Right  and  left  suprarenal  bodies,  right  and  left  kidneys, 
pancreas,  duodenum,  ascending  and  descending  colons,  rec- 
tum, bladder,  uterus. 

Describe  the  arteries  and  veins  passing  to  and  from  the 
kidneys. 

R^nal  artery,  bi"aneh  of  abdominal  aorta,  enters  hilum, 
breaks  up  into  branches  which  pa.ss  between  Malpighian  pyra- 
mids  to   coi'tico-medullary   junction,    then   sending  branches 


1  fifi  ANATOMY. 

into  cortex  and  medulla.  Veins  are  similarly  arrano:ed,  be- 
ginning in  interior  of  kidney ;  they  leave  by  passing  through 
sinus  and  hilum,  knoAvn  as  renal  vein,  to  join  inferior  cava. 

Give  the  anatomy  of  the  bladder,  including  blood  and 
nerve  supply. 

A  reservoir  in  the  pelvis,  partially  covered  by  peritoneum, 
consisting  of  involuntary  muscular  fibres  extending  in  longi- 
tudinal and  circular  directions,  a  submucosa  and  a  mucous 
membrane,  the  latter  possessing  transitional,  squamous  epithe- 
lial cells.  Blood  supply  is  from  internal  iliac  artery,  through 
superior,  middle  and  inferior  vesical  branches;  nerve  supply 
is  from  pelvic  plexus  of  sympathetic  and  from  3d  to  4th 
sacral  nerves. 

Describe  the  testes. 

They  are  two  seminal  glands  contained  within  the  scrotal 
cavity,  suspended  by  tlie  spermatic  cord,  and  surrounded  by 
a  peritoneal  process,  the  tunica  vaginalis  testis.  Each  gland 
consists  of  a  fibrous  stroma,  the  tunica  albuginea.  dividing 
the  interior  into  compartments  which  contain  the  seminiferous 
tubules,  the  latter  converging  toAVard  the  posterior  part  of 
the  gland,  and  emerging  to  constitute  the  epididymis. 

Describe  the  structure  of  the  prostate  gland  and  give 
its  anatomical  relations. 

It  possesses  a  capsule  of  fibrous  tissue,  enclosing  voluntary 
and  involuntary  muscle  and  branched  tubular  glands  opening 
into  prostatic  urethra;  base  is  closely  applied  to  "  neck  "  of 
bladder,  circular  muscular  fibres  of  which  are  continued 
around  prostatic  urethra,  which  pierces  prostate  from  'base 
to  apex;  behind  is  rectum;  in  front  is  pubo-prostatic  plexus 
of  veins  separating  it  from  symphysis  pubis;  ejaculatory 
ducts  pass  through  gland  between  middle  and  lateral  lobes. 

With  what  bones  does  the  clavicle  articulate? 

Sternum,  cartilage  of  fii-st  rib,  scapula. 


ANATOMY.  167 

Give  the  origin  and  distribution  of  ttie  median  nerve. 

FoiTued  by  branch  from  outer  and  one  from  inner  cord  of 
brachial  plexus  in  axillary  space,  over  front  of  axillary  artery, 
is  in  close  relation  to  brachial  artery  to  bend  of  elbow,  when 
branches  are  distributed  to  all  superficial  muscles  in  front  of 
forearm  except  flexor  carpi  ulnaris:  a  branch  known  as  ante- 
rior interosseous  supplies  outer  half  of  flexor  profundus,  flexor 
longus  pollicis  and  pronator  quadratus  (deep  nuLscles)  ;  in 
the  palm  the  median  is  distributed  to  integument  of  flexor 
surface  of  thumb,  index,  middle  and  middle-fincrer  half  of 
ring  finger  and  their  contiguous  sides,  and  dorsum  of  distal 
segment  of  thumb  and  fingers  (21/0),  motor  branches  to  ab- 
ductor and  opponens  pollicis,  sui)ei'ficial  head  of  flexor  brevis 
pollicis  and  two  outer  lumbricales. 

Where  is  the  fissure  of  Sylvius  and  what  artery  does  it 
•contain? 

Begins  at  anterior  perforated  space,  separates  frontal  and 
parietal  lobes  from  temporal  lobe,  passes  upward  and  back- 
ward to  terminate  in  parietal  lobe;  contains  middle  cerebral 
artery. 

Name  the  branches  of  the  brachial  artery. 

Superior  profunda,  nutrient,  muscular,  inferior  profunda, 
anastomotica  magna,  radial  and  ulnar  (terminals). 

Name  the  component  parts  of  the  spermatic  cord. 

Spermatic  artery,  spermatic  vein.s  (pampiniform  plexus), 
vas  defei-ens,  deferential  artery  and  defei-eiitial  veins,  lym- 
phatics, nerves   (spermatic  plexus  of  .sympathetic). 

What  forms  the  internal  hamstrings? 

Tendons  of  semitendinosus,  .semimembranosus,  gracilis. 

Describe  the  location  of  the  intercostal  arteries. 

Ill  the  intercostal  groove  near  the  lower  border  and  innei- 
surface  of  the  i-ib ;  aiitei-iorly  it  occupies  the  upper  part  of 
the  interc(>.sta]  space. 


168  ANATOMY. 

What  bone  forms  the  heel  and  with  what  does  it  artic- 
ulate? 

Os  calcis;  with  astragalus  and  cuboid. 

What  arteries  supply  the  heart  with  blood,  and  where 
do  they  originate? 

Coronary  (2),  springing  from  arch  of  aorta  just  above 
sinuses  of  Valsalva  of  aortic  semilunar  valve. 

Name  the  structures  located  in  the  inguinal  canal  and 
give  their  anatomical  relations. 

Spermatic  cord  in  male,  i-ound  ligament  in  female.  Are  in 
relation  with  walls  of  inguinal  canal,  which  are,  anterior, 
external  oblique  aponeurosis  entire  length,  conjoined  tendon 
(internal  oblique,  transversalis)  for  outer  third;  posterior, 
transversalis  fascia  and,  at  inner  end,  insertion  of  conjoined 
tendon;  floor  is  formed  by  Poupart's  ligament  and  trans- 
vei-salis  fascia;  roof  by  arched  fibres  of  conjoined  tendon. 

Describe  the  thoracic  duct. 

Begins  upon  body  of  second  lumbar  vertebra  in  dilated 
pouch  called  receptaculum  chyli,  passes  through  aortic  open- 
ing in  diaphragm,  then  through  posterior  mediastinum,  and 
at  base  of  neck  arches  to  left,  terminating  at  junction  of  left 
subclavian  and  internal  jugular  veins.  It  drains  the  lymph 
from  all  parts  of  body  except  right  upper  extremity,  right 
side  of  head  and  neck,  right  half  of  thorax  (right  lung  and 
right  side  of  heart)  and  upper  surface  of  liver. 

Describe  the  pleura. 

A  closed  sei'ous  sac  lining  the  thoracic  wall  (parietal  layer)  ^ 
from  which  it  is  reflected  to  the  lung,  investing  it  (visceral 
layer),  dipping  into  the  fissures  and  sending  process  from 
root  of  lung  to  diaphragm  (ligamentum  latum  pulmonis). 

Name  the  seven  openings  into  the  pharynx, 

Two  posterior  nares,  two  Eustachian  orifices,  mouth,  larynx^ 
esophagus. 


ANATOMY.  169 

Locate  and  describe  the  spleen. 

Is  in  the  left  hypochondriac  region,  dorsallv,  to  left  of 
fundus  of  stomach  and  to  left  of  tail  of  pancreas;  is  in  con- 
tact with  under  surface  of  diaphragm,  which  separates  it 
from  8th,  9th,  10th  and  11th  ribs.  It  has  convex  outer  sur- 
face, antero-internal  and  postero-internal  surfaces,  is  entirely 
covered  by  peritoneum,  at  hilum  splenic  artery  breaks 
up  into  branches  to  enter  gland  (duetle.s.s)  and  splenic 
vein  leaves  interior.  Anterior  border  is  notched :  capsnle 
invests  it  and  sends  trabe<*ula?  into  interior  at  hilum. 
dividing  it  into  compartments,  or  areola?,  which  contain 
splenic  pulp.  AVall  of  arteriole  becomes  thickened  with  lym- 
phoid material,  which  thickenings  are  known  as  ]\[ali>igliian 
corpuscles.  [Minute  arterioles  terminate  abruptly  in  areola*, 
where  blood  mi.xes  witli  splenic  pulp.  Color  of  spleen  is 
purple. 

What  bones  make  up  the  pelvis?  Give  the  gross  anat= 
omy  of  the  bony  pelvis. 

Two  ossa  innominata  (ilium,  ischium,  os  pubis),  sacrum  and 
coccyx.  Bony  pelvis  consists  of  upper  expanded  i)ortion 
called  the  false  pelvis,  and  lower  slightly  cordiforni  cavity 
known  as  the  true  pelvis.  The  true  pelvis  has  inlet,  cavity 
and  outlet,  conjugate  (antero-posterior),  transvei*se  and  ob- 
lique diametei*s. 

Mention  the  muscular  and  the  ligamentous  attachments 
of  the  patella. 

Quadriceps  extensor  femoris  (rectus,  va.st.us  intei-iius  and 
e.xteruus,  crureu.s)  ;  ligamentum  patellge. 

Describe  the  wrist-joint. 

Is  formed  by  radius  and  ti'iangular  cartilage  above,  sca- 
phoid, semilunar  and  cuneiform  below.  (Ulna  is  separated 
from  cuneifonn  by  triangular  interarticular  cartilage,  lience 
is  excluded  fi-om  wi-ist-joint").  Ligaments  are  anterior  and 
posterior,  external  and  inlci'iial  lateral.  Movements  are 
flexion,  extension,  ahdnction.  eircnniduction. 


170  ANATOiMY. 

What  muscles  assist  in  mastication?     In  deglutition? 

(a)  Temporal,  internal  and  external  pterygoids,  masse ter. 
(b)  Mylo-hyoid.  digastric,  stylo-hyoid  (first  part  of  act)  ; 
omo-hyoid,  sterno-hyoid,  sterno-thyroid.  thyro-hyoid  (second 
part  of  act). 

State  (a)  the  nerve  supply  of  the  rectum,  (b)  the  blood 
supply  of  the  rectum. 

(a)  Sympathetic  branches  from  inferior  mesenteric  and 
hypogastric;  plexuses  inferior  hemorrhoidal,  branch  of  in- 
ternal pndic.  (b)  Superior  and  middle  hemorrhoidal  arter- 
ies, branches  of  inferior  mesenteric  and  anterior  trunk  of 
internal  iliac  respectively;  inferior  hemorrhoidal,  branch  of 
internal  pudic. 

Describe  the  internal  jugular  vein. 

Is  formed  just  below  jugular  foramen  by  lateral  and  infe- 
i-ior  petrosal  sinuses;  courses  down  neck  beneath  anterior 
border  of  sterno-cleido-mastoid  muscle,  in  a  common  sheath 
with  the  internal  carotid  (above),  common  carotid  (below), 
and  pneumogastric  nerve,  the  latter  behind  and  between,  and 
the  artery  to  the  inner  side  of  the  vein,  which  partially  over- 
laps the  artery.  Behind  sternal  end  of  clavicle  it  unites  v^^ith 
subclavian  to  form  innominate  vein. 

With   what  bones  does  the  radius  articulate? 

Humerus,  ulna,  scaphoid  and  semilunar. 

Name  the  branches  of  the  abdominal  aorta. 

Two  phi'enics,  celiac  axis  (brs.  gastric,  hepatic,  splenic), 
superior  and  inferior  mesenteric,  suprarenals,  renals,  lumbar 
arteries  (4),  spermatic  or  ovarian,  middle  sacral  and  right 
and  left  common  iliacs. 

What  are  the  anterior  and  posterior  boundaries  of  the 
axilla,  and  what  arteries  and  nerves  pass  through  it? 

Anterior  boundary:  Pectoralis  major  and  minor.  Poste- 
j-ior    boundary:    Subcapularis.    teres    major    and    latissimus 


ANATOMY.  171 

dorsi.  Arteries  passing  through :  Axillary  and  its  branches 
(superior  thoracic,  acromial  thoracic,  long  thoracic,  alar  tho- 
racic, subscapular,  anterior  and  posterior  circumflex). 
Nerves  pa.ssing  through:  Brachial  plexas,  consisting  of  outer, 
middle  and  inner  cords,  with  branches  as  follows :  ]\Iusculo- 
cutaneous,  internal  and  lesser  internal  cutaneous,  circumflex, 
ulnar,  musculo-spiral,  median. 

Give  the  origin  and  distribution  of  the  third  division 
of  the  fifth  pair  of  nerves. 

Origin:  From  Gasserian  ganglion  at  apex  of  petrous  bone, 
passes  through  foramen  ovale  with  motor  root,  with  which  it 
now  unites;  divided  into  anterior  and  posterior  division.^, 
anterior  being  mostly  motor  to  muscles  of  mastication  (tem- 
poral, pterygoids,  nia.sseter),  posterior  di\nsion  forming  infe- 
rior dental.  Avhich  furnishes  mylo-hyoid  to  muscle  of  same 
name,  branches  to  teeth,  incisor  and  m^ental  branches;  aun- 
culo-temporal,  sen.sory  to  ear  and  temple:  lingual,  which  re- 
ceives chorda  tympani  branch  of  facial  and  is  distributed  to 
tongue. 

Bound  Scarpa's  triangle,  and  mention  the  vessels  and 
nerve  in  it. 

Is  bounded  by  Poupart's  ligament  above,  sartorius  exter- 
nally, adductor  longus  internally;  vessels  are  common  and 
superficial  femoi'al,  profunda  femoris  arteries;  femoral  vein; 
nerve  is  anterior  crural. 

Give  the  location  and  describe  the  anatomical  striic  = 
ture  of  the  kidneys. 

Are  placed  in  loins,  resting  upon  psoas  raagnus  and  quad- 
ratus  lumboi-um  muscles,  upper  end  of  left  reaching  as  high 
as  uppei'  border  of  11th  rib,  upper  end  of  Hght  as  high  as 
lower  bordei-  of  llth  lib.  F'acli  is  capped  by  suprarenal  body. 
is  .surrounded  by  capsule  and  j)erin:'nal  connective  tissue  con- 
taining fat.  is  supjilitMl  by  renal  artery,  and  di-ained  by  renal 
vein  and  lymphatics;  lU'rves  from  i-enal  plexus  of  sympa- 
thetic system.      The  kidney  is  boa n -shaped,   notch  upon  inner 


172  ANATOMY. 

border  is  called  the  hihim.  leading  into  a  depression  or 
cavity  known  as  the  sinus;  here  the  renal  duct,  or  ureter, 
begins  and  the  vessels  and  nerves  enter  or  leave.  The  interior 
of  the  gland  consists  of  a  connective  tissue  parenchyma  sup- 
porting vessels  and  uriniferous  tubules,  arranged  as  cortex 
and  medulla;  the  cortex  contains  the  glomeruli  (coiled-up 
blood  vessels — "  little  ball  of  yarn  ")  and  some  of  the  tubules; 
the  medulla  consists  of  pyramids  (Malpighian  or  medullary) 
made  of  parallel  collecting  tubules,  which  terminate  upon 
the  apex  of  the  pyramid,  pouring  urine  into  the  calices  of  the 
"'  pelvis  of  the  kidney,"  the  upper  expanded  portion  of  the 
ureter.  The  uriniferous  tubules  begin  around  a  glomerulus^ 
as  a  closed  extremity  (capsule  of  Bowman),  then  pass  tor- 
tuously through  the  cortex  down  into  the  medulla  and  back 
again  into  the  cortex  (loop  of  Henle),  terminating  in  one  of 
the  collecting  tubules  found  in  the  pyramid  of  Ferrein,  whose 
base  is  in  apposition  with  the  base  of  a  medullary  pyramid. 

Describe  the  mesentery. 

Is  a  double  fold  of  peritoneum  attached  to  posterior  ab- 
dominal wall  in  an  oblique  line  extending  between  the  left 
side  of  the  body  of  the  second  lumbar  vertebra  to  the  right 
sacro-iliac  joint,  a  distance  of  about  eight  inches.  Between 
its  two  layers  are  found  arteries,  veins,  lymphatics  (lacteals), 
lymphatic  nodes  (mesenteric  "  glands  "),  and  more  or  less 
fat ;  to  its  expanded,  convoluted  edge  the  small  intestine  is 
attached,  the  mesenteric  layers  surrounding  it  and  constitut- 
ing its  serous  covering. 

Give  the  name  and  location  of  the  various  glands  found 
in  the  small  intestine. 

Glands  in  small  intestine:  Duodenal  ("  Bruner's  "),  in 
duodenum;  intestinal  follicles  (''  crypts  of  Lieberkuhn  "),  in 
whole  length  of  small  and  large  intestine;  solitary  glands,  in 
wall  of  small  intestine,  collected  into  colonies  in  ileum,  tlien 
known  as  Peyer's  [)atehes. 


ANATOMY.  173 

Give  a  brief  yet  comprehensive  description  of  the  heart. 

Base  corresponds  to  upper  level  of  third  costal  cartilage, 
one  inch  to  right  of  sternal  margin  and  one-half  inch  to  left ; 
apex  to  fifth  intercostal  space  just  internal  to  vertical  line 
dia-wn  through  left  nipple;  base  is  directed  upward  and  back- 
ward to  the  right,  apex  downward,  forward  and  to  the  left. 
Is  surrounded  by  fibro-serous  sac  called  pericardium,  consist- 
ing of  two  layei"S,  fibrous  externally,  serous  internally,  the 
latter  lining  sac  (parietal  layer)  and  covering  heart  (visceral 
layer) ,  it  Ls  attached  to  central  tendon  of  diaphragm.  Right 
auncle  has  openings  of  superioi-  and  inferior  venae  cava?  and 
coronary  sinus;  right  ventricle  receives  blood  from  right 
auricle  through  right  auriculo-ventricular  opening  (tricuspid 
valve) ,  and  expels  it  through  conus  arteriosus  into  pulmonary 
artery,  which  is  guarded  by  pulmonary  semilunar  valve ;  right 
ventricle  contains  colunuiag  earneae,  musculi  papillares,  chordae 
tendinejE  attached  to  the  tricuspid  valve  segments;  left  auricle 
has  four  openings  for  pulmonary  veins  and  left  auriculo- 
ventricular  opening,  guarded  by  mitral  valve ;  left  ventricle 
has  columnse  earneae,  etc.,  like  right,  its  wall  is  thicker;  it 
forms  apex  of  heart,  and  blood  leaves  it  by  passing  into  aorta, 
which  is  guarded  by  aortic  semihmar  valve;  coronary  arteries 
(2),  branches  of  aorta  above  semilunar  valve,  supply  heart 
muscle.  Heart  is  lined  with  endocardium.  Pneumogastrics 
and  cardiac  plexuses  of  sympathetic  nervous  system  supply 
heart. 

What  forms  the  external  malleolus? 

Lower  end  of  fibula. 

Describe  one  of  the  vertebrae. 

Consi.sts  of  centrum,  or  body,  projecting  anteriorly,  with 
arch  behind,  made  up  of  two  (lateral)  pedicles,  converging 
laminiE  to  foi-m  spinous  process,  ti^nsverse  process  on  each 
side,  superior  and  inferioi"  pair  of  articular  jirocesses.  inter- 
vertebral notcli  on  under  side  of  each  pedicle. 


174  ANATOMY. 

Describe  the  position  of  the  palmar  arterial  arches. 

Superficial  palmar  arch  is  placed  upon  tendons  of  flexor 
subliinis  digitorum,  extending  across  palm  at  level  of  line 
draiwn  transversely  at  angle  of  w^eb  between  thumb  and  index 
finger ;  deep  arch  lies  upon  metacarpal  bones  and  interossei 
muscles,  one-half  inch  nearer  carpus  than  superficial  arch. 

What  blood  vessels  pass  to  and  from  the  liver? 

To  it,  hepatic  artery,  portal  vein;  umbilical  vein  in  foetus; 
from  it,  hepatic  veins. 

Describe  the  pyloric  orifice  of  the  stomach. 

Is  directed  backward  and  to  right,  is  near  neck  of  gall- 
bladder, consists  of  special  thickening  of  stomach  wall  pro- 
duced by  circular  muscular  fibers,  which  have  sphincter-like 
action. 

What  tissues  of  the  abdominal  wall  are  divided  in  the 
operation  for  appendicitis? 

Skin,  superficial  fascia,  external  oblique  muscle,  internal 
oblique  and  transversalis  muscles,  transversalis  fascia  (pre- 
peritoneal fat),  peritoneum.  Or,  skin,  superficial  fascia,  linea 
semilunaris,  transversalis  fascia,  peritoneum. 

With  what  bones  does  the  frontal  articulate? 

Both  parietal,  both  malar,  both  nasal,  both  lachrymal,  both 
maxilla;  (superior),  ethmoid,  sphenoid. 

Give  the  course  and  relations  of  Stenson's  duct. 

Is  formed  in  parotid  gland,  emerges  from  its  anterior  bor- 
der, resting  upon  masseter  muscle  a  finger's  breadth  below 
zygoma ;  it  then  perforates  buccinator  muscle,  runs  forward 
and  pierces  mucous  membrane  of  cheek  wall  opposite  upper 
middle  molar  tooth. 

Describe  the  Fallopian  tubes  and  give  their  relations. 

Oviducts  are  attached  to  cornua  of  uterus,  extend  laterally 
to  a  point  near  pelvic  brim,  here  expanding  into  fimbriated 
extremity;   one   of  the  fimbriaB  is  attached  to   ovary    (tubo- 


ANATOMY.  175 

ovarian  ligament).  Each  tube  is  lined  with  mucoius  mem- 
brane thrown  into  folds,  possessing  columnar,  ciliated  epithe- 
lium, outside  of  which  is  muscular  coat  of  internal  circular 
and  external  longitudinal  fibres,  the  whole  being  covered 
by  peritonemn  of  'broad  ligament.  Ovarian  and  uterine 
arteries  anastomose  along  their  lower  border;  fimbriated  ex- 
tremity is  in  close  relation  to  ovary;  outer  part  of  broad 
ligament,  extending  from  tube  to  pelvic  wall,  is  called  infun- 
dibulo-pelvie  ligament,  and  contains  ovarian  artery  and  veins. 

Describe  the  dura  mater.  Mention  the  processes  and 
sinuses  of  the  dura  mater. 

Forms  the  lining  or  eudosteum  of  cranial  cavity,  and  ex- 
tends through  foramen  magnum  into  neural  Ccinal  as  external 
layer  of  theca  of  cord;  is  tough  and  fibrous,  foi-ms  projec- 
tions or  shelves  in  cranial  cavity  for  support  of  encephalon. 
These  are  falx  cerebri,  falx  cerebelli,  tentorium  cerebelli. 
Dura  consists  of  two  layer's,  endosteal  and  meningeal,  which 
separate  at  certain  places  to  permit  the  entrance  of  the  tunica 
intima  of  a  vein,  thus  forming  venous  sinuses  of  cranium. 
These  are  superior  and  inferior  longitudinal,  straight,  two 
lateral,  occipital,  two  superior  and  inferior  petrosal,  trans- 
verse, circular,  and  two  cavernous. 

Give  the  macroscopic  and  the  microscopic  appearance  of 
(a)  kidney  tissue,  (b)  lung  tissue,  (c)  nerve  fiber. 

(a)  Kidney  tissue  is  moderately  fii-m,  somewhat  granular, 
reddish-brown  in  color.  Microscopically  it  presents  glomer- 
uli, uriniferous  tubules,  blood  vessels  and  interstitial  con- 
nective ti.ssue.  (b)  liUng  tissue  is  of  a  mottled  pink  color, 
soft  and  porous.  Under  the  miscroscope  it  shows  bronchioles 
(fibrous  wall  of  elastic  tissue  lined  with  mucous  membrane) 
and  alveoli,  dilatations  lined  witli  nuicous  membrane  of  squa- 
mous epithelial  cells,  outside  of  which  are  seen  capillary  blood 
vessels,  (e)  Nerve  fibre  is  cord-like,  soft  and  white.  Histo- 
logically it  consists  of  axis  cylinder  surrounded  by  white 
substance  of  Schwann  (medullary  substance)   (absent  in  non- 


176  ANATOMY. 

mediillated  nerves)    and  encased  in  the  neurilemma.     Inter- 
ruptions in  the  medullary  substance  occur  (nodes  of  Ranvier). 

What  anatomical  parts  are  normally  found  in  the  left 
hypochondriac  region? 

Fundus  of  stomach,  spleen  and  tail  of  pancreas,  splenic 
flexure  of  colon,  part  of  left  kidney. 

Give  in  language  or  by  drawing  the  normal  curvatures 
of  the  spinal  column,  and  describe  a  typical  cervical  ver= 
tebra. 

Curves  are  cervical,  thoracic,  lumbar,  sacro-coccygeal ; 
convexity  is  forward  in  cervical,  backward  in  thoracic, 
fonvard  in  lumbar,  backward  in  sacro-coccygeal.  The  line  of 
gravity  of  the  trunk  passes  through  the  chords  of  these 
curves.  A  typical  cervical  vertebra  consists  of  a  small  body, 
diverging  pedicles,  a  bifid  spinous  process,  bifid  transverse 
process  grooved  on  upper  border,  with  a  costo-transverse  fora- 
men for  vertebral  artery  at  base  of  transverse  process ;  neural 
foramen  is  relatively  large. 

Name  the  bones  and  ligaments  of  the  ankle=joint. 

Tibia,  fibula,  astragulus:  anterior  and  posterior,  internal 
(deltoid)    and  external  lateral  ligaments. 

Name  the  principal  muscles  that  keep  the  body  erect 
on  the  thigh  and  give  the  origin  and  insertion  of  any  one 
of  them. 

rJluteus  maximus,  gluteus  medius,  gluteus  minimus,  ham- 
strings ;  gluteus  maximus  takes  its  origin  from  outer  surface 
of  ilium  between  posterior  part  of  crest  and  superior  gluteal 
line,  from  vertebral  aponeurosis,  two  last  pieces  of  sacrum, 
posterior  surface  of  great  saero-sciatic  ligament,  and  is  in- 
serted into  gluteal  ridge  of  femur  and  ilio-tibial  band  of 
fascia  lata. 

Give  the  origin,  distribution  and  branches  of  the  middle 
meningeal  artery. 

Is  branch  of  internal  maxillary,  passes  through  foramen 


ANATOMY.  177 

spinosum  of  sphenoid,  traverses  wall  of  middle  cranial  fossa, 
dividing  into  anterior  and  posterior  branches  (meningeal) 
supplying  dura  and  bony  wall  of  cranium. 

Where  does  the  glosso=pharyngeal  nerve  rise  and  what 
structures  are  supplied  by  this  nerve  and  its  branches? 

Arises  from  groove  between  olivary  and  restiform  bodies, 
passes  out  of  cranial  cavity  through  jugular  foramen,  divides 
into  lingual  and  pharyngeal  branches,  supplying  mucous 
membrane  of  posterior  part  of  tongue  (circumvallate  papillae) 
and  mucous  membrane  of  pharynx.  A  branch  (Jacobson's) 
is  distributed  to  tympanum. 

Describe  the  pharynx. 

Belongs  to  both  respiratory  and  alimentaiy  tracts,  is  lined 
with  mucous  membrane  possessing  ciliated  columnar  cells 
-above,  and  squamous,  stratified  cells  below  level  of  soft  pal- 
ate; pharyngeal  aponeurosis  is  between  mucous  membrane 
and  constrictor  muscles;  constrictor  muscles  are  three  in 
number,  superior,  middle,  inferior.  Pharynx  is  flattened  an- 
tero-posteriorly,  is  widest  opposite  greater  cornua  of  hyoid 
bone,  and  communicates  with  posterior  nares,  with  middle 
•ears  by  Eustachian  tubes,  with  mouth,  larynx  and  esophagus. 
The  pharyngeal  tonsil  is  located  upon  upper  posterior  wall, 
and  consists  of  a  special  collection  of  adenoid  tissue,  which 
is  found  more  or  less  freely  distributed  throughout  naso- 
pharynx. 

Name  the  regions  of  the  abdomen. 

Draw  transverse  line  through  anterior  superior  iliac  spines; 
also  through  costal  cartilages  of  10th  ribs;  intersect  with  ver- 
tical lines  through  center  of  Poupart's  ligament.  Nine  re- 
gions thus  formed  are,  from  above  downward,  right  and  left 
hypochrondriac,  epigastric,  right  and  left  lumbar,  umbilical, 
right  and  left  inguinal,  hypogastric. 

Locate  and  describe  the  cecum. 

Firat  part  of  large  intestine,  found  below  ileo-cecal  junc- 
12 


178  ANATOMY. 

tion  in  right  iliac  fossa;  is  entirely  surrounded  by  peritoneum, 
possesses  sacculations,  that  upon  right  side  usually  larger, 
thus  throwing  original  (fetal)  apex  to  left,  at  which  point 
appendix  vermiformis  is  attached.  Longitudinal  musculax 
bands  well  defined. 

Describe  the  eyeball  and  give  its  parts. 

Is  spherical  in  shape,  embedded  in  orbital  fat,  has  ocular 
muscles  attached  to  it.  is  perforated  by  optic  nerve  and  ciliary 
arteries  and  veins,  posterior  five-sixtks  opaque,  anterior  one- 
sixth  transparent.  Its  walls  are  made  up  of  sclerotic  and 
cornea,  uveal  tract  (choroid)  and  retina,  enclosing  crystalline 
lens  and  vitreous  body.  Behind  cornea  is  anterior  chamber 
containing  aqueous  humor;  in  front  of  crystalline  lens  is  iris. 

Give  the  names  of  five  muscles  of  the  male  perineum. 

Ischio-cavernosus,  compressor  urethraB,  bulbo-cavernosus, 
transversus  perinei.  sphincter  ani  extemus. 

Name  five  muscles  of  the  back  of  the  leg. 

Gastrocnemius,  plantaris.  soleus,  tibialis  posticus,  flexor 
longus  digitorum. 

Name  the  principal  divisions  and  subdivisions  of  the 
internal  carotid  artery. 

It  divides,  after  passing  through  cavernous  sinus,  into  ante- 
rior and  middle  cerebral  arteries;  its  subdivisions  are  oph- 
thalmic and  posterior  communicating. 

Locate  and  describe  the  iIeo=cecal  valve. 

Is  found  at  junction  of  ileum  with  cecum,  formed  by 
ileum  passing  upward  and  outward  to  the  right  to  meet  large 
bowel  obliquely ;  its  orifice  is  a  horizontal  slit  projecting  into 
cecal  lumen. 

Describe  either  the  ascending  or  descending  vena  cava. 

Ascending  vena  cava  is  formed  by  union  of  the  two  com- 
mon iliac  veins  upon  body  of  fifth  lumbar  vertebra,  passes 
upward,    resting    on   bodies   of    vertebra   to    right    of    aorta,. 


ANATOMY.  179 

pierces  diaphragm  at  caval  opening,  and  almost  immediately 
enters  right  auricle.  Its  tributaries  are  lumbar  veins,  right 
spermatic  vein  (or  ovarian),  renal  veins,  hepatic  veins,  phre- 
nic veins. 

Name  the  bones  that  form  the  ankle°joint  and  give  their 
relations. 

Tibia  and  fibula  above,  with  internal  and  external  malleoli, 
respectively,  forming  mortise  for  astragalus,  whose  trochlear 
surface  and  sides  fill  up  the  spaee  between  the  two  bones  of 
the  leg. 

What  muscles  form  the  quadriceps  extensor  crureus  and 
where  is  its  conjoined  tendon  inserted? 

Rectus  femoris,  vastus  externus.  vastus  internus.  crureus; 
tendon  is  inserted  into  tubercle  of  tibia. 

With  what  bones  does  the  malar  articulate? 

Frontal,  supei-ior  maxilla,  temporal,  sphenoid. 

What  arteries  supply  the  bladder  in  the  male,  and  from 
what  are  they  branches? 

Supt'rioi-.  iniddle  and  inferior  vesical,  branches  of  anterior 
trunk  of  int<'nuil  iliac. 

In  an  amputation  of  the  forearm,  3  inches  above  the 
wrist,  what  arteries  will  it  be  necessary  to  tie,  and  of 
what  are  they  branches? 

Radial  and  ulnai"  arteries,  branches  of  the  brachial;  interior 
and  posterior  interosseous  arteries,  braiu'hes  of  tlie  ulnar. 

Locate  the  4th  ventricle  of  the  brain. 

Flooi-  is  foi-iiK'd  l)y  medulla  and  pons,  bordeis  by  inferior 
and  su{)ei-ior  peduncles  of  cerebellum,  witli  middle  peduncles 
at  lateral  angles;  r(M)f  is  formed  by  valve  of  Vieussens,  or 
Kuperioi-  iiHMlullary  velum,  above,  inferior  medullai-y  velum 
.ind  tchi  clKU'oidea  inferior  ])elow. 

Locate  and  briefly  describe  the  gall-bladder. 

Is  placed    upon   under  surface  of  I'iglil   lobe  of  liver,  in  so- 


180  ANATOMY. 

called  fissure  for  gall-bladder;  fundus  projects  beyond  ante- 
rior border  of  liver.  Is  a  pear-shaped  sac  covered  by  perito- 
neum, having  a  rounded  end  called  the  fundus,  and  a 
constricted  posterior  extremity  known  as  the  neck,  which  is 
continued  into  the  cystic  duct.  Its  wall  is  composed  of 
fibrous  and  muscular  tissue,  and  it  is  lined  with  mucous 
membrane,  which  is  thrown  into  corkscrew-like  folds  at  the 
neck  and  the  beginning  of  the  cystic  duct. 

Describe  the  esophagus  as  to  (a)  location,  (b)  dimen= 
sions,  (c)  arterial  supply. 

Is  located  behind  trachea,  and  in  posterior  mediastinum, 
extending  from  lower  end  of  pharynx  to  cardiac  end  of  stom- 
ach at  esophageal  orifice  of  diaphragm.  It  is  10  inches  long; 
its  arterial  supply  is  by  branches  from  the  inferior  thyroid 
(thyroid  axis  of  subclavian),  thoracic  aorta,  gastric  (coeliac 
axis),  left  phrenic. 

Describe  the  rectum  as  to  structure,  length  and  con= 
tained  glands. 

Extends  from  third  piece  of  sacrum  to  anus,  curved  for- 
ward. From  third  piece  of  sacrum  to  tip  of  coccyx  is  par- 
tially covered  by  peritoneum.  Its  walls  consist  of  peritoneum 
or  fibrous  tissue  externally,  within  which  is  muscular  coat  of 
longitudinal  and  circular  fibres;  then  comes  submucosa  sup- 
porting mucous  membrane,  the  latter  forming  fixed,  trans- 
verse folds  (plicae  recti,  or  valves  of  Houston),  two  or  three 
in  number,  extending  transversely  around  portion  of  rectum. 
Glands  are  of  mucous  variety. 

How  is  the  eye  supplied  with  blood? 

By  the  ophthalmic  artery,  forming  ciliary  branches  and 
arteria  centralis  retinae. 

What  is  the  circle  of  Willis? 

An  arterial  anastomosis  at  base  of  brain,  formed  by  inter- 
nal carotid  arteries  as  follows:  Each  internal  carotid  sends 
forward  the  anterior  cerebral,  which  is  connected  with  the 


ANATOMY.  181 

opposite  anterior  cerebral  by  the  anterior  communicating;  it 
furthermore  sends  backward  the  posterior  communicating 
which  meets  the  posterior  cerebral,  which  is  a  branch  of  the 
basilar. 

Name  and  bound  the  ventricles  of  the  brain. 

The  lateral  ventricles  (first  and  second)  are  bounded  above 
by  corpus  callosum;  below  by  intraventricular  portion  of 
corpus  striatum,  taenia  semicircularis,  choroid  plexus,  optic 
thalamus,  posterior  pillar  of  fornix,  corpus  fimbriatum;  in- 
ternally by  septum  lucidum.  Third  is  bounded  above  by 
velum  interpositum ;  below  by  gray  matter  at  base  of  brain, 
i.  e.,  lamina  cinerea,  tuber  cinereum,  corpora  albicantia,  pos- 
terior perforated  space  and  tegmenta  of  crura  cerebri ;  later- 
ally 'by  optic  thalami ;  anteriorly  by  lamina  cinerea  and 
anterior  pillars  of  fornix ;  posteriorly  by  posterior  commis- 
sure and  pineal  gland  (epiphysis  cerebri).  Fourth  ventricle 
is  bounded  above  by  valve  of  Vieussens  (superior  medullary 
velum)  in  the  middle  by  epithelial  lining  and  pia;  below 
by  inferior  medullary  velum;  tloor  is  formed  above  by  pons, 
below  by  medulla;  sides  are  formed  by  superior,  middle  and 
inferior  cerebellar  peduncles. 

Describe  the  sympathetic  nerve,  naming  and  locating 
the  principal  ganglia. 

Consists  of  a  double  chain  of  ganglia  extending  along 
either  side  of  vertebral  column  anteriorly,  connected  by 
branches  with  each  other  and  with  spinal  nerves  (rami  com- 
municantes),  furnishing  branches  to  blood  vessels  (vaso- 
motor nerves)  and  forming  plexuses — three  prevertebral 
plexuses  and  numerous  secondary  plexuses  around  arteries. 
Principal  ganglia  are  ophthalmic,  in  back  part  of  orbit; 
spheno-palatine,  in  spheno-maxillary  fossa ;  submaxillary, 
upon  submaxillary  gland ;  semilunar,  upon  aorta  around 
coeliac  axis. 

Give  the  origin,  insertion  and  action  of  any  one  of  the 


182  ANATOMY. 

following    muscles:    occipito=frontalis,    deltoid,    gastrocne-= 
mius. 

Deltoid  arises  from  outer  third  anterior  border  of  clavicle, 
outer  margin  of  acromion,  lower  ])order  of  spine  of  scapula, 
entire  length,  and  is  inserted  into  deltoid  impression  upon 
outer  surface  of  middle  of  shaft  of  humerus.  Action,  to 
abduct  arm  to  horizontal  position.     Nerve,  circumflex. 

What  arteries  unite  to  form  the  basilar  artery? 

The  two  vertebrals. 

Describe  the  tongue. 

Consists  of  intrinsic  and  extrinsic  nuiscles.  Intrinsic  are 
different  divisions  of  lingualis  (superior,  inferior,  transverse 
and  vertical)  ;  extrinsic  are  geniohyoglossus,  hyoglossus,  stylo- 
glossus, palatogiassus.  Tongue  is  supported  by  hyoid  bone, 
is  covered  by  mucous  membrane  thickh^  set  with  papillae,  viz., 
circum  vail  ate  at  base,  fungiform  and  filiform  upon  dorsum 
and  margin.  Nerves :  Motor,  hypoglossal ;  sensory  and  gus- 
tatory, glosso-pharyngeal,  lingual,  chorda  tympani. 

Describe  the  pia  mater. 

Innermost  of  three  meninges,  is  closely  applied  to  central 
nervous  system,  supporting  blood  vessels,  dipping  down  into 
sulci  and  passing  into  general  ventricular  cavity  of  encepha- 
lon  to  develop  choroid  plexiLses — vascular  fringes  found  in 
lateral,  third  and  fourth  ventricles. 

Describe  the  bones  of  the  hand  with  their  divisions  and 
articulations. 

Carpus,  metacarpus,  phalanges.  Eight  carpal  bones :  Sca- 
phoid, semilunar,  cuneiform,  pisiform,  trapezium,  trapezoid, 
OS  magnum,  unciform.  Five  metacarpal  bones;  fourteen  pha- 
langes. Carpal  articulate  with  each  other  and  with  bases  of 
metacarpals;  scaphoid  and  semilunar  articulate  with  radias; 
cuneiform  \^^th  triangiilar  interarticular  cartilage  betnveen 
it  and  ulna;  metacarpals  articulate  with  each  other  at  their 


ANATOMY.  183 

base  and  with  firet  phalanges  at  their  heads;  phalangas  artic- 
ulate with  each  other  and  with  metacarpals. 

Describe  the  hip=jolnt. 

Enarthrodial,  or  ball-and-socket  joint,  formed  by  acetab- 
ulum and  head  of  femur,  surrounded  by  capsule,  most  im- 
portant and  strongest  part  of  which  is  found  upon  the  an- 
terior aspect  of  the  joint,  extending  between  anterior  inferior 
spine  of  ilium  and  anterior  intertrochanteric  line  (spinal  line 
of  femur),  and  is  known  as  the  "Y"  ligament  (ilio- femoral). 
This  ligament  prevents  hyperextension  of  thigh  upon  pelvis, 
or  falling  backward  of  trunk.  Capsule  is  attached  to  innom- 
inate bone  around  margin  of  acetabulum  and  to  neck  of 
femur;  ligamentum  teres  is  attached  to  head  of  femur  and  to 
bottom  of  acetabulum.  ^Movements  permitted :  Flexion,  ex- 
tension, abduction,  adduction,  rotation  and  circiunduction. 

Name  five  muscles  of  the  shoulder  and  arm.  Give  the 
origin,  insertion  and  action  of  any  one  of  the  five. 

Deltoid,  coraco-brachialis,  biceps,  triceps,  teres  major, 
biceps  takes  origin  by  two  heads,  one  from  coracoid  process  of 
scapula,  the  other  from  upper  margin  of  glenoid  fossa,  this 
tendon  passing  through  shoidder-joint  to  reach  bicipital 
groove;  insertion  is  into  deep  fascia  of  forearm  by  semilunar 
(bicipital)  fascia,  and  into  bicipital  tuberosity  of  radius; 
action  is  to  tiex  forearm  uj)()n  ai'm.  and  to  supinate  liand. 

Give  the  origin,  course  and  branches  of  any  one  of  the 
following  arteries:  brachial,  temporal,  left  common  carotid. 

Loft  oounuon  carotid  arises  from  afch  of  aorta,  coui-ses 
upward  and  outward  in  line  drawn  from  stemo-clavicular 
joint  of  mastoid,  dividing  at  level  of  upper  border  of  thyroid 
cartilage  into  its  ordy  braTiches.  external  and  internal  carotids. 

Describe  the  hemispheres  and  lobes  of  the  brain. 

The  cerebral  hemispheres  are  ovoid,  convex  upon  superior 
and  lateral  surfaces,  partially  separated  from  each  other  by 
longitudinal     fissure,    but    connected     by    corpus    callosum. 


184  ANATOMY. 

Frontal  lobe  occupies  anterior  fossa  of  cranial  cavity,  sep- 
arated from  parietal  lobe  by  fissure  of  Rolando,  and  from 
anterior  part  of  temporal  lobe  by  Sylvian  fissure;  parietal 
lobe  is  bounded  by  fissure  of  Rolando  anteriorly,  parieto- 
occipital fissure  posteriorly,  Sylvian  fissure  inferiorly,  great 
long-itudinal  fissure  superiorly;  occipital  lobe  is  found  be- 
hind parieto-occipital  fissure;  temporal  lobe  is  below  fissure 
Sylvius,  and  rests  in  middle  cranial  fossa. 

Where  in  the  topography  of  the  abdomen  is  the  sigmoid 
flexure  located?     The  appendix  vermiformis? 

(a)  In  left  inguinal  and  hypogastric  regions,  (b)  In  right 
inguinal  region. 

Give  the  surgical  anatomy  of  femoral  hernia. 

Neck  of  sac  is  at  femoral,  or  crural,  ring  formed  by  Gim- 
bemat's  ligament  on  inner  side,  femoral  vein  on  outer,  Pou- 
part's  ligament  in  front,  and  horizontal  ramus  of  pubic  bone 
behind ;  is  closed  by  septum  crurale ;  crural  canal  is  narrow 
interval  between  femoral  vein  and  femoral  sheath  on  inner 
side  of  vein,  and  extends  from  crural  ring  above  to  upper 
margin  of  saphenous  opening  below.  Saphenous  opening  is 
closed  by  cribrifoi-m  fascia. 

Describe  the  esophagus. 

Extends  from  lower  margin  of  cricoid  cartilage  to  stomach, 
is  ten  inches  long,  situated  behind  trachea  in  neck  and  in 
posterior  mediastinum  in  thorax ;  curves  forward  lo  esopha- 
geal opening  in  diaphragm,  through  which  it  passes,  accom- 
panied by  pneumogastric  nerves;  wall  consists  of  external 
longitudinal  and  internal  circular  muscle  fibres,  a  submucosa 
and  a  mucous  membrane,  which  is  thrown  into  longitudinal 
folds,  and  is  made  up  of  stratified  epithelial  cells. 

Describe  the  formation  of  the  teeth. 

The  teeth  are  composed  of  three  substances — the  enamel,, 
the  dentine  and  the  cementum.  The  enamel  covers  the  ex- 
posed part  of  the  tooth,  the  crown  of  the  tooth.     The  cemen- 


ANATOMY.  185^ 

turn  covers  the  part  of  the  tooth  within  the  alveolus  of  the  jaw. 
The  junction  of  the  enamel  with  the  cementum  is  called  the 
neck  of  the  tooth.  The  bulk  of  the  tooth  is  made  up  of  the 
dentine,  which  extends  from  the  root  to  the  crown.  Each 
tooth  contains  a  cavity,  the  pulp  cavity,  which  communicates 
with  the  exterior  through  a  small  aperture  at  the  apex  of  the 
root,  the  apical  foramen.  The  cavity  contains  a  soft  connec- 
tive tissue — the  pulp,  rich  in  vessels  and  nerves.  The  fang, 
or  root,  of  the  tooth  has  a  fibrous  investment  called  the  peri- 
dental membrane,  or  periosteum. 

Give  a  brief  description  of  the  facial  nerve. 

The  7th  cranial  nerve,  after  passing  through  facial  canal 
(aqueductus  Fallopii)  of  temporal  bone,  emerges  at  the  stylo- 
mastoid foramen,  and  enters  substance  of  parotid  gland. 
Here  it  divides  into  two  sets  of  branches,  temporo-facial  and 
cervico-facial,  supplying  muscles  of  expression.  Its  chorda 
tympani  branch  traverses  inner  surface  of  membrana  tym- 
pani.  after  leaving  main  trunk  in  facial  canal,  and  emerging 
through  one  end  of  the  Gasserian  fissure  unites  with  lingual 
branch  of  5th  and  accompanies  it  to  submaxillary  gland  and 
ganglion  and  anterior  %  of  mucous  membrane  of  tongue. 

Describe  the  eIbow=joint. 

Is  a  ginglymus,  or  hinge- joint,  made  up  of  lower  end  of 
humerus  and  upper  ends  of  radius  and  ulna;  head  of  radius 
articulates  with  capitellum,  and  greater  sigmoid  cavity  of 
ulna  with  trochlear  surface  of  humerus.  Its  capsule  is 
divided  into  anterior  and  posterior,  internal  and  external 
lateral  ligaments.  It  permits  of  flexion  and  extension.  It  is 
Inbi-icated  by  synovial  membrane  lining  its  capsule. 

Describe  the  superior  vena  cava. 

Is  formed  by  union  of  right  and  left  innominate  (jugulo- 
eephalie)  veins,  just  below  cartilage  of  first  rib  (close  to  right 
boixier  of  sternum)  ;  is  nearly  three  inches  long  and  termin- 
ates in  right  auricle;  it  receives  vena  azygos  major. 


18B  ANATOMY. 

Describe  the  temporo=maxillary  articulation,  mentioning 
the  ligaments. 

Bony  parts  are  glenoid  fossa  and  articulating  eminence  of 
temporal  bone,  and  condyle  of  mandible ;  ligaments  form  a 
capsnle.  mneh  stronger  externally  and  posteriorly;  external 
lateral  ligament  extends  between  tubercle  of  zygoma  and 
neck  of  condyle:  associated  ligamentous  bands  are  spheno- 
mandibnlar  and  stylo-mandibular -.  an  interarticnlar  cartilage 
contained  \Aathin  the  joint  cavity  has  tendon  of  insertion  of 
external  pterygoid  muscle  attached  to  it.  JNIovements  per- 
mitted are  depression  and  elevation  of  jaw  around  a  trans- 
vei'se  axis,  and  a  sliding  forward  of  both  sides,  protruding 
chin,  or  of  one  side  at  a  time,  producing  a  triturating  move- 
ment. 

Describe  the  maxillary  sinus  (or  antrum  of  Highmore). 

Is  a  triangular  cavity  contained  in  body  of  maxilla,  lined 
with  mucous  membrane  and  communicating  with  middle 
meatus  of  nose  through  one  or  two  small  openings;  apex  of 
caAnty  is  formed  by  malar  process  of  maxilla;  base  is  formed 
by  outer  wall  of  nose;  in  its  posterior  wall  are  posterior 
dental  canals  for  posterior  dental  vessels  and  nerves  to  the 
teeth ;  in  floor  are  usually  seen  several  elevations,  corres- 
ponding to  roots  of  1st  and  2d  molar  teeth. 

Describe  the  aorta. 

Springs  fr<mi  left  ventricle,  anteriorly,  extends  upward 
to  upper  border  of  right  2d  costal  cartilage,  then  arches 
backward  to  left  and  descends  thi"ough  thorax,  resting  upon 
vertebral  bodies,  passes  through  aortic  opening  in  diaphragm 
and  courses  through  abdominal  cavity  as  far  as  body  of  4th 
lumbar  vertebra. 

Branches  are:  Two  coronary  from  ascending  j)Oi'tion;  in- 
nominate, left  common  carotid  and  left  subclavian  from  arch; 
bronchial,  intercostal,  pericardiac,  esophageal  and  posterior 
mediastinal  from  thoracic  portion;  2  phrenic  lumbar,  sacra 
media     (parietal    branches),    celiac    axis     (g:astric,    hepatic, 


ANATOMY.  187 

splenic),  superior  mesenteric,  inferior  mesenteric  (single 
branches  from  front),  suprarenal,  renal,  spennatic  (or 
ovarian)   (lateral  paired  branches)  from  abdominal  portion. 

Describe  the  trachea  and  give  its  anatomical  relations. 

It  extends  from  the  larynx  to  the  bronchi,  and  consists  of 
a  series  of  transversely  directed,  incomplete  rings  of  cartilage 
united  by  aji  elastic  membrane  which  contains  involuntary 
muscle-fibre  posteriorly,  where  the  cartilaginous  ring  is  de- 
ficient ;  it  is  lined  with  a  mucous  membrane  which  is  covered 
with  ciliated  columnar  epithelial  cells. 

The  trachea  rests  upon  the  esophagiLS,  being  tlattened  pos- 
teriorly ;  in  the  groove  between  these  two  structures  is  the 
recurrent  laryngeal  nerve,  upon  each  side;  the  common  caro- 
tid ai"tery,  internal  jugular  vein  and  pneumogastric  nerve 
are  close  to  it  at  its  lower  portion,  while  the  isthnnis  of  the 
thyroid  body  ci"osses  it  upon  its  second  and  third  rings,  and 
the  lobes  of  the  same  rest  upon  it  laterally. 

Describe  the  pulmonary  veins. 

They  are  four  in  number,  usually.  2  for  each  lung,  and 
return  arterial  bk>od  from  lungs  to  left  auricle  of  heart. 

Describe  the  spinal  column. 

It  consists  of  38  separate  vertebrse,  distributed  as  follows : 
7  cervical.  12  thoracic,  5  lumbar,  5  sacral,  4  coccygeal.  Sacral 
and  coccygeal  coalesce  early  in  life  by  ossification  of  inter- 
vertebral substances:  cervical  segment  passesses  curve  with 
convexity  forward,  thoracic  with  convexity  backward,  lum- 
bar witli  convexity  forward,  sacral  with  convexity  backward; 
line  of  gravity  passes  through  chords  of  these  curves. 
Special  or  peculiai-  vertebne  are:  Atlas,  axis,  7th  cervical 
(^vertclira  {vrominens)  :  riljs  articulate  with  thoracic  .series; 
ilia  articulate  with  saenim.  Spinal  colunm  contains  neural 
<'aiial  for  spiiia.l  coi'd. 

Give  the  minute  anatomy  of  the  skin. 

The  skill  consists  of  t.he  cutis  vera.  foniK^d  of  tibi-ous  tissue. 


188  ANATOMY. 

the  superficial  layer  being  raised  into  numerous  papillae. 
This  is  the  vascular  layer  of  the  skin.  The  end  bulbs  of  the 
sensory  nerves  are  found  here  also.  Covering  the  cutis  vera 
is  the  epidermis,  formed  of  numerous  layers  of  epithelium. 
There  are  four  strata  of  the  epithelium :  The  outer,  horny,  or 
stratum  corneum ;  the  stratum  lucidum ;  the  stratum  granu- 
losuni,  and  the  inner  or  stratum  mucosum. 

Give  a  general  description  of  the  alimentary  canal,  nam= 
Ing  its  successive  divisions. 

Its  parts,  in  order,  are :  Mouth,  pharynx,  esophagus, 
stomach,  small  intestine  (duodenum,  jejuno-ileum),  large  in- 
testine (cecuTii,  ascending,  transverse,  descending  and  sigmoid 
colons,  rectum  and  anal  canal). 

Mouth  is  composed  of  upper  and  lower  jaws  covered  by 
cheek  walls,  with  buccal  orifice  directed  transversely;  con- 
tains tongue,  at  base  of  which  are  fauces  with  anterior  and 
posterior  pillars  and  tonsils. 

Pharynx  joins  esophagus  at  lower  border  of  cricoid  carti- 
lage; esophagus  is  10  inches  long  and  passes  through  dia- 
phragm to  be  continued  into  stomach. 

Stomach  occupies  epigastric  and  left  hypochondriac  regions 
and  presents  a  eardiac  and  a  pyloric  extremity  and  a  greater 
and  lesser  curvature.  Its  wall  consists  of  4  coats,  viz.,  serous, 
muscular,  areolar  and  mucous. 

Duodenum  is  fixed  and  curved  around  head  of  pancreas; 
conuuon  bile  and  pancreatic  ducts  open  into  it;  jejuno-ileum, 
attached  to  posterior  abdominal  wall  by  mesentery,  extends 
for  20  feet,  or  more,  to  ileo-cecal  junction,  where  it  joins 
large  intestine;  venniform  appendix  is  attached  to  cecum 
(usually  inner  side),  below  ileo-cecal  valve;  ascending  colon 
passes  to  liver,  forms  hepatic  flexure ;  transverse  colon,  with 
great  omentum  attached,  crosses  to  spleen  and  forms  splenic 
flexure;  descending  colon  reaches  left  iliac  fossa  and  is  con- 
tinued into  sigmoid  which  curves  around  into  pelvis,  resting 
on  sacrum ;  rectum  curves  forward  and  anal  canal,  guarded 
by  internal  (involuntary)  and  external  (voluntary)  sphinc- 
ters, opens  downward  and  slightly  backward. 


ANATOMY.  189 

State  the  origin  and  exit  of  the  pneumogastric  nerve. 

Superficial  origin,  from  side  of  medulla  in  groove  between 
olivary  and  restiform  bodies;  exit,  through  jugular  foramen. 

Describe  the  mastoid  portion  of  the  temporal  bone. 

Mastoid  bone  is  placed  behind,  is  rough  and  convex  exter- 
nally and  projects  downward  and  forward  as  mastoid  process; 
beneath  are  digastric  fossa  for  posterior  belly  of  digastric 
muscle,  and  occipital  groove  for  occipital  artery;  within  sub- 
stance of  mastoid  are  mastoid  cells,  the  largest  of  which  is 
called  mastoid  antrum,  which  communicates  with  middle  ear; 
upon  cerebral  surface  of  mastoid  is  sigmoid  groove  for  lat- 
eral sinus. 

Describe  the  lateral  sinuses. 

Right  and  left  lateral  sinuses  commence  at  internal  occip- 
ital protuberance,  right  being  formed  by  superior  longitu- 
dinal sinus,  left  by  straight  sinus;  are  located  in  attached 
margin  of  tentorium,  grooving  occipital,  parietal,  mastoid  and 
occipital  bone  again,  leaving  cranial  cavity  through  jugular 
foramen,  just  outside  of  which  they  unite  with  inferior  pe- 
ti-osal  sinus  to  form  internal  jugular  vein. 

Give  the  origin  and  insertion  of  the  muscles  which  form 
the  anterior  triangles  of  the  neck. 

The  antei'ior  common  triangle  is  bounded  above  bj'  the 
lower  border  of  the  mandible  and  a  line  extending  backward 
from  the  angle  of  the  mandible  to  the  mastoid  process  of  the 
temporal  bone ;  in  front,  by  the  median  line  of  the  neck ; 
behind,  by  the  anterior  border  of  the  sterno-mastoid  muscle. 
This  common  triangle  is  divided  into  the  submaxillary,  su- 
perior carotid  and  inferior  carotid  triangles,  by  the  posterior 
belly  of  the  digastric  muscle  above  and  the  anterior  belly  of 
the  omo-hyoid  below. 

Sterno-mastoid  inuscle :  Origin,  from  anterior  surface  of 
upper  part  of  manubrium  sterni  and  inner  third  of  anterior 
])()id('r  of  clavicle;  insertion,  into  mastoid  process  of  temporal 
;ui(l  oiilor  lijilf  of  supoi-ioi-  curved  line  of  occipital  bone. 


190  ANATOMY. 

Omo-hyoid  muscle :  Origin,  froni  uppei-  border  of  scapula 
to  inner  side  of  suprascapular  notch ;  insertion,  into  body  of 
hyoid  bone. 

Digastric  muscle :  t)rigin  of  posterior  belly  is  from  digastric 
fossa  of  mastoid  portion  of  temporal  bone,  and  of  anterior 
belly  from  lower  border  of  mandible  close  to  symphysis;  in- 
sertion, into  central  tendon,  which  is  attached  to  body  and 
greater  comu  of  hyoid  bone. 

Name  and  describe  the  course  of  the  arteries  supplying 
the  hand. 

Radial  and  ulnar  arteries.  Course  of  radial  artery  is  from 
just  below  bend  of  elbow  down  radial  border  of  forearm  to 
outer  side  of  wrist,  where  it  tui'iis  over  on  to  dorsum  of  hand, 
passes  down  through  proximal  end  of  first  interosseous  space 
to  reach  palm,  now  passing  transversely  across  deep  part  of 
palm  to  anastomose  with  deep  conuuunicating  branch  of  ulnar 
artery. 

C'Ourse  of  ulnar  artery  is  from  near  head  of  radius  in  a 
curve  over  to  ulnar  border  of  forearm,  thence  along  ulnar 
border  to  radial  side  of  pisiform  bone,  where  it  divides  into 
a  superficial  branch,  to  form  superficial  palmar  arch  and  a 
deep  branch  to  complete  deep  arch. 

Locate  and  describe  the  ovaries. 

The  ovaries  are  located  ordinarily  close  to  lateral  part  of 
time  pelvic  brim,  attached  to  posterior  layer  of  broad  liga- 
ment. They  somewhat  resemble  a  broad  almond,  are  li/^ 
inches  in  length,  whitish  in  color,  with  an  uneven,  puckered 
surface,  and  consist  of  a  covering  of  germinal  epithelium, 
and  a  stroma  which  encloses  ovisacs,  vessels  and  nerves. 

Locate  and  describe  the  principal  convolutions  of  the 
brain. 

Ascending  frontal  convolution  bounds  the  fissure  of  Ro- 
lando anteriorly,  and  belongs  to  the  frontal  lobe;  ascending 
parietal  convolution  bounds  the  fissure  of  Rolando  posteriorly, 
and  is  a  par-t  of  the  parietal  lobe.     In  these  convolutions  are 


ANATOMY.  191 

ioeated    important    motor    nerve-centers,    controlling:    nerves 
which  are  distributed  to  the  opposite  side  of  the  body. 

The  cuueus  is  a  convolution  belonging-  to  the  mesial  surface 
of  the  occipital  lobe,  between  the  internal  parieto-occipital 
and  calcarine  fissures;  in  it  are  located  the  cortical  centers 
of  sight. 

Describe  the  palmar  fascia. 

It  consists  of  a  central  and  two  lateral  portions.  Central 
portion  is  thick  and  binds  down  tendons  and  protects  vessels 
and  nerves;  it  is  narrow  above  where  it  is  attached  to  an- 
terior annular  ligament;  below  it  is  broad  and  divides  into 
4  slips  for  the  four  fingers,  these  being  attached  to  under 
surface  of  skin  at  base  of  fingei-s,  to  sides  of  metacarpo-pha- 
iangeal  joints  and  to  sides  of  metacarpal  bones  near  their 
distal  ends. 

Give  the  origin  and  insertion  of  the  muscles  of  the 
scapulo-humeral  joint. 

Supi'aspinatus.  infraspinatus,  teres  minor,  subscapularis. 
deltoid,  bice{)s  and  triceps. 

Supraspinatus :  Origin,  from  inner  %  of  supraspinous 
fossa ;  insertion,  into  highest  facet  of  greater  tuberosity  of 
humerus,  and  blending  intimately  with  capsular  ligament  of 
shoulder  joint. 

Infraspinatus:  (Irigin.  fi'()m  inner  -/-^  of  iiifraspinous  fossa; 
insei'tion,  into  miildle  facet  of  greatei-  tul)ei-osity,  als<i  blend- 
iii<i-  witli  capsulai"  ligament. 

Teres  minor:  Oi-igin,  from  upper  %  of  axillary  border  of 
scapula :  ins<M-ti()n.  into  lowest  facet  of  greater  tuberosity, 
also  hleiidinu:  with  capsular  ligament. 

Subscapulai-is :  Origin,  from  greater  pai't  of  subscapular 
fossa;  insertion,  into  lessoi-  tubei'osity  of  humerus,  its  tendon 
of  insertion  al.so  ])len(ling  closely  with  capsular  ligament. 

Deltoid:  Oi'igin.  from  outer  ' -.  of  anterioi*  l)order  of  cla- 
vicle, fi'om  outer  nuirgin  of  aci-omion  and  lower  border  of 
spine  of  scapula;  inser-tion,  into  i-ough.  triangular'  area  on 
outer  side  of  sh;it'l   of  Imiiieriis  nenr  its  middle. 


192  ANATOMY. 

Biceps :  Origin,  from  coracoid  process  and  from  upper 
margin  of  glenoid  cavity  (short  and  long  heads,  respectively)  ; 
insertion,  into  bicipital  tuberosity  of  radius  and  by  bicipital 
(or  semilunar)  fascia,  into  deep  fascia  of  forearm. 

Triceps:  Origin,  from  axillaiy  border  of  scapula  just  be- 
low glenoid  cavity  (long  or  scapular  head),  and  from  pos- 
terior surface  of  humerus,  one  head  above,  the  other  below, 
the  musculo-spiral  groove  (2  short  or  humeral  heads)  ;  inser- 
tion, into  olecranon  process  of  ulna. 

Describe  the  nasal  fossae. 

Are  2  irregular  cavities  in  middle  of  face,  on  either  side 
of  median  line,  separated  from  each  other  by  mesially  placed 
nasal  septum ;  they  extend  upward  to  anterior  floor  of  cranial 
cavity,  and  dowuAvard  to  roof  of  mouth;  they  open  anteriorly 
by  2  large  apertures,  the  anterior  nares,  and  communicate 
with  naso-pharynx  by  posterior  nares. 

Roof  is  narrow,  and  formed  in  center  by  cribriform  plate 
of  ethmoid,  anteriorly  by  nasal  bones  and  nasal  spine  of  fron- 
tal, posteriorly  by  under  surface  of  body  of  sphenoid.  Roof 
contains  apertures  in  cribriform  plate  for  olfactory  nerves; 
behind  are  openings  leading  into  sphenoidal  sinuses. 

Floor  is  smooth,  wider  in  middle  than  at  either  end,  and 
is  formed  by  palate  process  of  maxilla,  a.uteriorly.  and  by 
palate  process  of  palate  bone  post-eriorly. 

Inner  wall  consists  of  septum,  which  is  made  up  of  crest 
of  nasal  bones  and  spine  of  frontal,  by  perpendicular  plate 
of  ethmoid,  by  vomer  and  by  rostrum  of  sphenoid,  and  below 
by  crests  of  maxillary  and  palate  bones.  A  large  notch  at  an- 
terior extremity  of  bony  septum  receives  the  septal  cartilage. 

Outer  wall  is  formed,  in  front,  by  lachrymal  bone  and  nasal 
process  of  maxilla;  in  the  middle,  by  ethmoid,  inner  surface 
of  maxilla,  and  inferior  turbinated :  behind,  by  vertical-plate 
of  palate  bone  and  internal  pterygoid  plate  of  sphenoid. 
The  outer  wall  contains  3  irregular,  longitudinal  passages, 
viz.,  superior,  middle  and  inferior  meati :  the  superior  meatus 
{smallest)  is  located  at  upper  and  back  i)art  of  nasal  fossa, 


ANATOMY.  193 

is  between  superior  and  middle  turbinated  bones,  and  com- 
municates with  spheno-maxillary  fossa  by  spbeno-palatine 
foramen,  and  with  posterior  ethmoidal  cells  by  an  opening  in 
its  outer  wall.  (Opening  for  sphenoidal  sinus  is  above  and 
behind  superior  turbinated  bone).  Middle  meatus  is  situ- 
ated between  middle  and  inferior  turbinated  bones.  It  con- 
tains, anteriorly,  the  orifice  of  the  infundibulum.  by  which 
the  middle  meatus  is  placed  in  communication  with  the  an- 
terior ethmoidal  cells  and  the  frontal  siniTses;  the  middle 
ethmoidal  cells  and  maxillary  antrum  also  open  into  middle 
meatus.  Inferior  meatus  is  the  largest,  is  formed  by  inferior 
turbinated  above  and  floor  of  nasal  fossa  below;  it  contains, 
under  cover  of  the  inferior  turbinated,  anteriorly,  the  termin- 
ation of  the  naso-lachrymal  duct. 

Name  and  locate  the  accessory  sinuses  of  the  face  and 
describe  their  outlets. 

Frontal  sinuses,  contained  between  outer  and  inner  tablas 
of  frontal  bone  above  supraorbital  arch,  communicate  through 
infundibulum  with  anterior  ethmoidal  eells  and  middle  nasal 
meatus. 

Ethmoidal  cells,  comprising  greater  part  of  lateral  mass 
of  ethmoid  bone,  and  divided  into  anterior,  middle  and  pos- 
terior. Anterior  and  middle  ethmoidal  cells  open  into  middle 
na.sal  meatus;  posterior  ethmoidal  cells  open  into  superior 
nasal  meatus. 

Sphenoidal  cells  (or  sinuses)  are  contained  within  body  of 
sphenoid  bone  and  communicate  with  upper,  back  part  of 
nasal  fossa. 

Maxillary  sinus  (antrum  of  Highmore)  is  situated  in  body 
of  maxilla;  its  outlet  is  an  aperture  communicating  with 
middle  meatus  of  no.se. 

Describe  the  iris,  giving  relations,  nerve  and  blood 
supply. 

It  is  an  ela.stic,  contractile  diaphragm,  forming  the  anterior 
extremity  of  the  middle,  pigmented  and  vascular  tunic  of  the 
13 


194  ANATOMY. 

eyeball.  By  its  peripheral  attached  border  it  is  directly  con- 
tinuous with  the  ciliary  body;  it  is  placed  in  front  of  the 
crystalline  lens,  and  incompletely  divides  the  anterior  cham- 
ber into  two  compartments.  Near  its  center  is  a  circular 
opening,  the  pupil,  which  varies  greatly  in  size.  In  structure 
the  iris  consists  of  a  stroma  of  delicate  fibrous  and  elastie 
tissue,  with  perhaps  some  involuntary  muscle  fibers.  It  is 
supplied  by  the  ciliary  nerves.  The  long  and  anterior  ciliary 
arteries  anastomose  and  form  a  vascular  circle  around  the 
attached  margin  of  the  iris,  sending  branches  in  toward  the 
pupillary  margin. 

Describe  the  course  and  distribution  of  the  nerves  of 
the  palm  of  the  hand. 

Median,  from  outer  and  inner  cords  of  brachial  plexus, 
accompanies  brachial  artery,  rests  upon  flexor  profundus^ 
digitorum  in  forearm,  passes  beneath  annular  ligament  into 
palm.  It  supplies  all  anterior  forearm  muscles  except  flexor 
carpi  ulnaris  and  ulnar  half  of  flexor  profundus  digitorum; 
cutaneous  branches  supply  palm,  thumb,  index,  middle  and 
half  of  ring  fingers  on  their  palmar  aspect  and  nail-beds,  and 
outer  two  lumbricales. 

Ulnar,  from  inner  cord,  descends  along  inner  border  of 
arm,  behind  inner  condyle  of  humerus,  then  between  flexor 
carpi  ulnaris  and  flexor  profundus,  both  of  which  it  supplies ; 
it  crosses  anterior  annular  ligament  with  ulnar  artery  and 
divides  to  supply  short  muscles  of  little  finger,  all  interossei, 
inner  two  lumbricales  and  flexor  bi'evis  and  adductor  pollieis; 
cutaneous  distribution  is  to  doi*sum  and  palm  of  hand  on 
ulnar  side,  and  to  little  finger  and  ulnar  half  of  ring  finger. 

Give  the  origin,  insertion  and  action  of  any  one  of  the 
following  muscles:  digastric,  sacrolumbalis,  rectus  ab- 
dominis. 

Rectus  abdominis  takes  its  origin  from  body  of  pubic  bone 
and  from  anterior  ligaments  of  pubic  symphysis  of  opposite 
side,  is  inserted  into  costal   cartilages  of  5th,  6th  and  7th 


ANATOMY.  195 

ribs;  contains  three  transverse  lines  (linea?  transversog), 
which  extend  in  zigzag  style  across  the  muscle  in  its  upper 
part ;  action  is  to  flex  thorax  upon  pelvis,  or  vice  versa,  and 
to  compress  abdominal  viscera. 

Give  four  principal  points  of  distribution  of  the  pneu- 
mogastric  or  par  vagum  nerve. 

Pharynx  (motor),  larynx  (motor  and  sensory),  heart 
(superficial  and  deep  cardiac  plexuses),  stomach  (uniting 
with  sympathetic  system). 

What  is  contained  in  the  middle  mediastinum? 

Heart  and  pericardium,  ascending  aorta,  lower  part  of 
superior  cava,  vena  azygos*  major,  both  bronchi,  pulmonary 
artery  and  veins,  phrenic  nerves. 

What  anatomical  parts  are  involved  in  the  descent  of 
the  testes? 

Gubernaeulum  testes,  visceral  and  parietal  layers  of  peri- 
toneum, transversalis  fascia,  inguinal  canal  and  rings,  inter- 
nal oblique  muscle  (cremaster  muscle  and  cremasteric  fascia), 
intercolumnar  fascia. 

Describe  the  bones  forming  the  ossa  innominata. 

Ilium  has  curved  crest  extending  from  anterior  superior  to 
posterior  spine;  internally  is  iliac  fossa  (false  pelvis,  limited 
below  by  ileo-pectineal  line)  ;  externally  are  superior,  middle 
and  inferior  gluteal  lines;  greater  sciatic  notch  is  behind, 
partly  formed  by  ischium ;  anterior  inferior  spine  for  rectus 
femoris  and  ilio-femoral  (Y)  ligament  is  below  anterior  supe- 
rior spine ;  iliyra  forms  part  of  true  pelvis  and  two-fifths  of 
acetabulum  •  fuses  with  os  pubis  and  ischium  at  18th  to  20th 
year;  articulates  with  sacrum  by  auricular  surface. 

Ischium  has  a  body  above,  with  spine  of  ischium  projecting 
backward  and  inward,  and  separating  greater  from  lesser 
sciatic  notches;  lesser  sciatic  notch  is  on  ischium  below 
spine ;  tuberosity  of  ischium  is  lowest  part,  from  which  ramus 
ascends  toward  pubic  bone  and  partially  bounds  obturator 


196  ANATOMY. 

foramen;  ischium  forms  two-fifths  of  acetabulum  and  part 
of  true  pelvis. 

Os  pubis  has  body  (articulates  with  opposite  bone,  forming 
symphysis  pubis)  ;  horizontal  and  descending  ramus,  bound- 
ing obturator  foramen;  pubic  spine  for  pubic  ligament; 
ilio-pectineal  line  extending  from  body  along  horizontal 
ramus;  on  under  surface  of  latter  is  groove  for  obturator 
vessels  and  i\erve. 

Describe  the  sternum,  its  articulation  and  the  import= 
ant  muscles  attached  to  it. 

Consists  of  manubrium,  gladiolus  and  ensiform  appendix; 
suprasternal  notch  is  above,  between  clavicles;  notches  are 
found  along  lateral  bordere  for  articulation  of  first  seven 
pairs  of  ribs  (costal  cartilages),  and  at  upper  outer  angles 
of  manubrium  for  clavicles;  transverse  ridge  (subcutaneous 
landmark)  exists  at  line  of  junction  of  manubrium  and  gladi- 
olus, marking  level  of  third  rib :  ensiform  varies  in  size  and 
shape.  Important  muscles  attached  are  sterno-cleido-mastoid 
and  pectoralis  major ;  rectus  abdominis  and  diaphragm  are 
attached  to  ensiform. 

What  portion  of  the  bladder  is  uncovered  by  perito= 
neum? 

The  anterior  wall,  which  is  separated  from  symphysis  pubis 
by  prevesical  space  (cavum  Retzii) . 

Describe  the  spinal  cord. 

Is  ■contained  in  neural  canal,  and  extends  from  lower  mar- 
gin of  foramen  magnum  to  body  of  second  lumbar  vertebra; 
constitutes  2  per  cent,  of  cerebro-spinal  axis ;  is  surrounded 
by  dura,  arachnoid  and  pia;  has  two  enlargements,  cervical 
and  lumbar,  which  mark  points  of  origin  of  large  nerve 
ti"unks  for  upper  and  lower  extremities  respectively  (brachial 
and  sacral  plexuses)  ;  white  nerve  matter  surrounds  gray, 
which  is  arranged  like  two  inverted  commas  (or  capital 
"H"),  connected  by  transverse  band  (gray  commissure)  ;  an- 
terior" horn  of  gray  matter  contains  large  multipolar  cells 


ANATOMY.  197 

continuous  with  motor  nerves,  which  appear  upon  surface  of 
cord  at  antero-lateral  aspect;  posterior  gray  horn  is  contin- 
uous with  sensory  nerves,  which  appear  upon  postero-lateral 
aspect  of  cord. 

Describe  the  hyoid  bone. 

Is  U-shaped,  placed,  with  convexity  forward,  above  thyroid 
cartilage ;  consists  of  centrally  located  body,  two  greater  cor- 
nua  directed  backward  and  two  lesser  cornua  projecting  up- 
ward at  point  of  junction  of  body  and  greater  cornua.  Hyoid 
bone  serves  for  attachment  of  thyro-hyoid  membrane  and 
ligament  and  stylo-hyoid  ligament;  of  sterno-hyoid,  thyro- 
hyoid, omo-hyoid,  genio-hyoid.  genio-hyoglossus,  hyoglossus, 
mylo-hyoid,  stylo-hyoid  and  digastric  muscles. 

Name  the  articulations  of  the  superior  maxillary  bone. 

Frontal,  Jachrymal,  nasal,  malar,  palate,  ethmoid,  inferior 
turbinal,  vomer  and  opposite  maxilla. 

Give  the  origin  and  distribution  of  the  olfactory  nerve. 

Olfactory  tract  appears  upon  surface  of  cerebrum  at  ante- 
rior perforated  space,  extends  fonvard,  terminating  in  olfac- 
tory bulb,  which  rests  upon  cribriform  plate  of  ethmoid ;  from 
under  surface  of  bulb  20  to  30  nerves  descend,  enter  superior 
nasal  meatus,  grooving  perpendicular  plate  and  superior  and 
middle  turbinal  processes  of  ethmoid,  and  are  distributed  to 
nasal  mucous  membrane  covering  these  parts. 

Describe  the  mammary  glands. 

Two  hemispherical,  lobulated  glands  placed  upon  anterior 
thoracic  wall  over  pectoralis  major  muscle,  covering  a  space 
from  the  second  to  the  sixth  rib,  and  from  margin  of  sternum 
to  anterior  margin  of  axilla.  Nipple,  sensitive  and  pig- 
mented, projects  from  center,  and  contains  orifices  of  lactif- 
erous ducts;  areola,  also  pigmented,  surrounds  nipple;  gland 
substance  is  arranged  in  lobules  (10  to  20),  each  of  which  is 
a  compound,  racemo.se  gland,  and  all  are  surrounded  and 
supported  by  fibrous  tissue,  forming  a  capsule. 


198  ANATOMY. 

Describe  each  of  the  tunics  of  the  eye  and  the  different 
parts  of  each. 

Sclerotic  is  outermost,  consisting  of  bundles  of  fibrous 
tissue  closely  interlaced,  is  perforated  to  nasal  side  of  pos- 
terior pole  by  optic  nerve,  and  is  continuous  with  cornea 
anteriorly.  Six  ocular  muscles  are  inserted  into  it.  Cornea 
is  transparent,  consists  of  bundles  of  fibrous  tissue  enclosing 
corneal  spaces,  in  which  are  lodged  corneal  corpuscles;  is 
covered  by  conjunctival  epithelium  and  lined  by  Descemet's 
membrane ;  is  richly  supplied  by  sensory  nerve  fibers,  but  is 
non-vascular.  Uveal  tract  consists  of  choroid,  ciliary  body 
and  iris,  is  vascular  and  pigmented ;  choroid  is  perforated  by 
optic  nerve  behind ;  ciliary  body  is  made  up  of  ciliary  pro- 
cesses and  ciliary  muscle ;  iris  is  placed  in  front  of  lens  in 
anterior  chamber,  and  is  perforated  at  its  center  (pupil). 
Retina  is  innermost  tunic,  made  up  of  nerve  cells  and  fibers, 
representing  an  expansion  of  the  optic  nerve ;  macula  lutea  is 
point  of  most  acute  vision,  and  is  located  to  temporal  side 
of  optic  disk,  or  point  of  entrance  of  optic  nerve ;  retina  is 
supplied  by  arteria  centralis  retinae,  branch  of  ophthalmic 
artery,  and  drained  by  central  vein  of  retina  into  ophthalmic 
vein. 

What  are  the  vesiculae  seminaies? 

Two  dilated  pouches  placed  between  bladder  and  rectum, 
uniting  with  vasa  deferentia  to  form  ejaculatory  ducts. 

Give  the  course  of  the  posterior  tibial  artery. 

Extends  from  lower  border  of  popliteus  muscle  down  leg 
between  superficial  and  deep  layers  of  muscles  to  inner  side 
of  ankle,  where  it  divides  into  internal  and  external  plantar 
branches. 

Which  of  the  cranial  nerves  has  the  widest  distribution? 

Pneumogastric  (10th). 

Describe  the  origin  and  distribution  of  the  ninth  pair  of 
cranial  nerves? 

Ninth,  or  glosso-pharyngeal,   nerve  has  superficial  origin 


ANATOMY.  199 

from  groove  between  olivary  and  restiform  bodies  of  medulla; 
is  distributed  to  pharynx  (sensory)  and  to  posterior  third 
of  tongue,  especially  to  circumvallate  papillae. 

Give  the  distribution  of  the  radial  nerve  below  the 
wrist. 

To  radial  half  of  dorsum  of  hand,  and  dorsum  of  thumb, 
index,  middle  and  middle-finger  half  of  ring  finger,  except 
distal  segments  of  digits,  which  are  supplied  by  median  nerve. 

What  is  the  linea  alba  and  how  is  it  formed? 

Is  the  line  of  fusion  of  aponeuroses  of  external  and  in- 
ternal oblique  and  transversalis  muscles,  extending  from  en- 
siform  above  to  symphysis  below;  just  below  its  center  is 
umbilicus. 

Describe  the  sphincter  ani. 

Are  two  in  number,  internal,  or  involuntary,  and  external, 
or  voluntary.  Internal  is  formed  by  circular  fibers  of  rectal 
wall;  external  is  attached  to  tip  of  coccyx,  surrounds  anal 
opening,  and  is  inserted  into  median  line  of  perineum. 

Describe  the  periosteum. 

Is  clasely  adherent  to  outer  surface  of  bone  and  consists 
of  two  layers,  an  outer,  fibrous  layer,  and  an  inner,  vascular 
layer.  In  young  and  growing  bones  the  inner  is  called  the 
osteogenetic  layer.  Nerves  and  lymphatics  are  also  present 
in  periosteum. 

Give  the  origin,  insertion  and  action  of  any  one  of  the 
following  muscles:  tibialis  anticus,  pronator  radii  teres, 
gracilis. 

Tibialis  anticus  arises  from  upper  %  of  outer  surface  of 
shaft  and  under  surface  of  outer  tuberosity  of  tibia,  from 
interosseous  membrane;  is  inserted  into  internal  cuneiform 
and  first  metatarsal  bones;  action,  to  flex  and  invert  foot;  to 
strengthen  and  help  maintain  antero-posterior  arch  of  foot. 

Give  a  general  description  of  the  cerebral  veins. 

llemarkable  for  lliinnoss  of  their  walls  due  to  lack  of  mus- 


200  ANATOMY. 

cular  tissue;  they  have  no  valves;  superficial  cerebral  veins 
are  lodged  in  sulci  between  convolutions,  receive  blood  from 
substance  of  brain  and  terminate  in  the  sinuses,  opening  into 
them  in  the  opposite  direction  to  which  blood  is  flowing; 
deep  cerebral  veins  drain  the  ventricles  into  straight  sinus  ^ 
at  base  basilar  vein  drains  interpeduncular  space  and  basal 
ganglia. 

Relate  the  differences  between  a  virgin  uterus  and  the 
uterus  of  a  multipara. 

Uterus  of  multipara  is  larger  (especially  body),  arbor  vitae 
uterinse  of  cervix  is  more  or  less  effaced,  external  os  is  irreg- 
ular, or  perhaps  stellate,  instead  of  being  a  smoothly  out- 
lined, transversely  directed  slit. 

Describe  a  hair  follicle  in  its  relations  to  the  skin. 

A  hair  follicle  is  an  involution  of  epidermis,  forming  a 
funnel-shaped  depression  sometimes  extending  into  subcutan- 
eous cellular  tissue;  is  usually  placed  obliquely  and  becomes 
enlarged  at  bottom  to  accommodate  hair  bulb,  part  of  which 
is  vascular  papilla  derived  from  dermal  lining  of  follicle; 
opening  into  follicle  are  ducts  of  one  or  more  sebaceous 
glands. 

What  are  the  Wormian  bones? 

Bones  developed  from  separate  centers  of  ossification  to  fill 
in  gaps  between  certain  of  the  cranial  bones ;  they  are  found 
most  frequently  in  lambdoid  suture,  occasionally  occupying 
position  of  fontanelles,  especially  posterior. 

Give  a  general  description  of  the  peritoneum.  Name 
the  principal  organs  covered  by  it. 

Is  a  closed  sac  (except  in  female,  at  orifices  of  Fallopian 
tubes)  which  lines  abdominal  wall  (parietal  layer)  and  par- 
tially or  completely  surrounds  viscera  (visceral  layer),  con- 
stituting their  serous  coat;  it  forms  omenta — Gastro-colic,  or 
great  omentum,  gastro-hepatic,  or  lesser  omentum,  and  gastro- 
splenic;  it  forms  mesenteries — Mesentery  (proper),  of  small 


ANATOMY.  201 

intestine,  mesocolon  (ascending,  transverse,  descending,  sig- 
moid, mesoappendix :  principal  organs  covered  by  peritoneum 
are:  liver,  stomach,  spleen,  small  intestine,  large  intestine, 
Fallopian  tubes,  uterus,  bladder. 

Describe  the  thymus  gland. 

Is  first  found  during  second  month  of  intrauterine  life,  is 
largest  when  child  is  two  or  three  years  old,  and  usually  dis- 
appears before  puberty ;  is  located  in  anterior  mediastinum 
and  lower  part  of  neck,  between  lungs,  in  front  of  heart  and 
great  vessels  and  trachea ;  consists  of  two  lobes  made  up  of 
lobules,  which  are  essentially  lymphatic  in  character. 

What  are  the  suprarenal  capsules  and  what  are  their 
relations  to  adjacent  organs  and  parts? 

Are  two  in  number,  one  placed  upon  the  upper  pole  of 
each  kidney ;  each  consists  of  cortex  and  medulla  with  vessels 
entering  and  leaving  at  a  hilum;  cortex  is  yellowish  in  color 
and  contains  granular,  polyhedral  cells  arranged  in  columns; 
medulla  is  darker  in  color,  from  presence  of  blood-vessels 
which  are  closely  related  to  groups  of  large  cells.  Supra- 
renal bodies  are  partially  covered  by  peritoneum  and  are  in 
relation,  right  with  under  surface  of  liver,  left  with  spleen, 
stomach  and  pancreas. 

Describe  the  medulla  oblongata. 

Is  a  part  of  encephalon,  continuous  with  spinal  coi*d  below 
and  with  pons  above ;  its  rests  upon  basilar  process  of  occip- 
ital bone,  consists  of  white  nerve  matter  externally  and  gray 
matter  arranged  irregularly  internally,  the  latter  appearing 
upon  the  surface  in  floor  of  fourth  ventricle,  the  lower  half 
of  which  is  formed  by  upper  surface  of  medulla;  ui>ou  ven- 
tral surface  is  anterior  median  fissure,  partially  obliterated 
below  by  decussation  of  crossed  pyramidal  tracts ;  near  an- 
terior part  of  inferior  surface  are  olivary  bodies;  posterior 
columns  diverge  to  form  calanuis  scriptorius  and  to  bound 
fourth  ventricle  laterally  for  its  lower  half;  postero-laterally 
are  restiform  l)odies  which  can  be  traced  upward  into  cere- 


202  ANATOMY. 

bellum,  forming  inferior  peduncles  of  latter.  Cranial  nerves 
from  seventh  to  eleventh  inclusive  arise  from  side  of  medulla, 
while  twelfth  appears  upon  surface  in  groove  between  olivary 
body  and  anterior  pyramid. 

Locate  and  describe  the  lachrymal  gland. 

Is  located  in  upper,  outer  and  anterior  part  of  orbit,  to 
inner  side  of  external  angular  process ;  is  made  up  of  lobules, 
■or  clusters  of  acini,  arranged  around  the  ducts,  six  to  twelve 
in  number,  which  empty  into  outer  part  of  superior  conjunc- 
tival fornix. 

Describe  the  lungs. 

Each  is  pyramidal  in  shape,  base  resting  upon  diaphragm, 
apex  extending  into  superior  aperture  of  thorax,  lateral,  con- 
vex surface  being  applied  to  thoracic  wall  and  inner,  mesial 
and  irregularly  concave  surface  looking  toward  mediastinum; 
each  possesses  a  root,  placed  upon  inner  surface,  near  pos- 
terior, thickened  margin,  and  consisting  of  bronchus,  pulmon- 
ary artery  and  vein,  bronchial  artery,  nerves  and  lymphatics ; 
right  lung  has  three  lobes,  left  has  two;  each  is  made  up  of 
lobules  consisting  of  a  terminal  bronchiole,  around  which  are 
arranged  clusters  of  air  cells;  each  lung  is  invested  by  vis- 
ceral layer  of  pleura,  whose  parietal  layer  lines  thoracic  wall. 

Describe  the  structure  of  the  knee=joint. 

Bones:  Femur,  tibia,  patella;  ligaments:  Internal  and  ex- 
ternal lateral,  ligamentum  patellas,  posterior;  these  are 
strengthened  and  supported  by  aponeuroses  of  vastus  externus 
and  internus  a.ntero-laterally.  semimembranous  posteriorly; 
chief  internal  ligaments  are  crucial,  anterior  and  posterior; 
joint-  contains  two  semilunar  cartilages  which  are  attached  to 
non-articular  area  upon  npper  surface  of  tibia;  synovial 
membrane  is  extensive  and  complieated;  movements:  Flex- 
ion, extension,  slight  rotation. 

Bound  the  popliteal  space.     Mention  its  contents. 

Above  bv  outer  and  inner  hamstrings,  below  by  outer  and 


ANATOMY.  203 

inner  heads  of  gastrocnemius  muscle,  with  plantaris  upon 
outer  side ;  contents  are :  Internal  and  external  popliteal 
nerves,  popliteal  vein  and  popliteal  artery,  termination  of 
short  saphenous  vein  and  small  lymphatic  glands. 

Mention  the  principal  branches  of  the  celiac  axis. 

Gastric,  hepatic  and  splenic  arteries. 
What  are  the  nerves  of  the  eyeball? 

Optic,  motor  oculi  and  ophthalmic  division  of  fifth  (both 
through  ophthalmic  ganglion)  and  sympathetic  fibers  from 
•cavernous  plexus  (also  to  ganglion). 

Describe  the  aural  labyrinth. 

Osseous  labyrinth,  whose  divisions  are  three  semicircular 
canals  posteriorly  placed,  a  vestibule  in  middle,  and  cochlea 
anteriorly,  all  containing  membranous  labyrinth  upon  which 
terminal  filaments  of  auditory  nerve  and  its  special  neuro- 
epithelium  are  found. 

Describe  the  popliteal  artery  and  give  its  branches. 

Is  a  continuation  downward  of  femoral  from  opening  in 
adductor  magnus  and  divides  at  lower  border  of  popliteus 
muscle  into  anterior  and  posterior  tibial  arteries;  it  lies  upon 
femur,  posterior  ligament  of  knee-joint,  tibia,  and  fascia  cov- 
ering popliteus  muscle;  it  enters  popliteal  space  at  upper 
inner  margin,  and  bisects  it  longitudinally;  popliteal  vein  is 
superficial  to  it;  branches  are  superior  and  inferior  internal 
and  external  articular,  azygos  articular,  sural  (muscular  to 
calf) ,  and  anterior  and  posterior  tibial. 

What  are  the  blood-vessels  which  supply  the  arteries 
called?     Whence  are  the  nerves  of  the  arteries  derived? 

(a)  Vasa  vasorum.  (b)  Vasomotor,  from  sympathetic 
system. 

Mention  the  varieties  of  epithelium. 

Squamous,  columnar,  ciliated,  glandular,  tran.sitional,  pig- 
mented, and  neuro-epithelium.     The  first  three  may  occur  in 


204  ANATOMY. 

a  single  layer,  when  it  is  named  "simple;"  or,  in  several 
layers,  when  it  is  called  "stratified." 

Describe  the  muscular  tissue. 

Muscular  tissue  is  of  mesodermic  origin  and  consists  prin- 
cipally of  elongated  cells  (fibrous  cells)  which  have  the  in- 
herent power  of  contracting.  The  muscle  fibers  contain  nuclei 
and,  sometimes,  that  which  corresponds  to  a  cell  wall,  the 
sarcolemma.  Voluntary  and  cardiac  muscles  are  striated,  due 
to  the  arrangement  of  alternate  light  and  dark  discs.  Non- 
striated  muscle  is  involuntary.  ^Microscopically,  they  may  be 
differentiated  as  follows : 

Striated.  Non=Striated.  Cardiac. 

Fibers     striated     trans-  No  striations  Striated    longitudinally 

versely.  and  transversely. 

Has  sarcolemma.  Hyaline  sheath.  No  sarcolemma. 

Nucleus  beneath  sacro-  Nucleus  in  center.  Nucleus     oval    and    in 

lemma.  center. 

Fibers  do    not   branch,  Fibers  short. 

except  in  the  tongue.  Fibers  branch  freely. 

Describe  a  Haversian  system. 

A  Haversian  system  occurs  in  compact  bone  and  consists 
of  a  system  of  channels  through  which  the  nutrient  fluids 
pass.  It  consists  of  the  following:  A  centrally  placed  canal, 
the  Haversian  canal,  which  is  surrounded  by  concentric  lay- 
ers or  plates  of  bone,  the  lamellse.  Between  the  plates  of 
bone  are  irregular  clefts,  the  lacunae,  which  communicate 
with  each  other  and  with  the  Haversian  canal  by  means  of 
radially  placed  canals — the  eanaliculi. 

Name  the  humors  of  the  eyeball. 

Aqueous  humor,  contained  in  anterior  chamber,  consists  of 
98.6%  water,  and  small  quantities  of  extractives  and  pro- 
teids ;  vitreous  humor,  occupying  the  large  posterior  chamber, 
has  about  the  same  composition  as  aqueous  humor. 

State  the  origin  of  the  sensory  division  of  the  fifth  pair 
of  cranial  nerves. 

Superficial  origin  is  from  under  .surface  of  pons,  close  to 
anterior  border. 


ANATOMY.  205 

What  is  the  function  of  the  third  cranial  nerve? 

To  supply  with  motor  influence  all  ocular  muscles  except 
superior  oblique  and  external  rectus,  and  to  furnish  motor 
root  to  ophthalmic  ganglion. 

Describe  the  ramus  of  the  jaw.  Mention  the  muscles 
and  ligaments  attached  to  the  ramus  of  the  jaw. 

Ramus  extends  upward  and  slightly  backward,  forming 
angle  of  jaw  by  its  junction  with  the  body;  is  surmounted 
by  coronoid  process  anteriorly  and  condyle  posteriorly,  be- 
tween which  is  sigmoid  notch;  upon  inner  surface  is  inferior 
dental  foramen. 

Muscles  and  ligaments  attached  are:  Temporal,  external 
and  internal  pterygoids,  masseter;  capsular  and  internal  lat- 
eral ligament  of  temporo-mandibular  articulation,  stylo-man- 
dibular  ligament. 

Describe  the  arytenoid  cartilages. 

Are  pyramidal  in  shape,  rest  upon  upper,  posterior  part  of 
cricoid  cartilage  by  their  bases,  have  true  vocal  cord  (thyro- 
arytenoid ligaments)  attached  to  vocal  process  anteriorly; 
lateral  crico-arytenoid,  posterior  crico-arytenoid,  arytenoid 
and  thyro-arytenoid  muscles  are  also  attached.  The  arytenoid 
cartilages  are  covered  with  mucous  membrane  and  between 
them  is  the  interarytenoid  space. 

Give  the  course  and  relations  of  the  external  jugular 
vein. 

Is  formed  near  angle  of  jaw  by  union  of  temporo-maxillary 
and  posterior  auricular  veins,  runs  downward  and  outward 
upon  sternomastoid  muscle  and  under  platysma  myoides,  to 
empty  into  subclavian  vein  at  middle  of  clavicle. 

Mention  the  branches  of  the  internal  iliac  artery. 

Anterior  trunk:  Superior,  middle  and  inferior  vesical,  ob- 
turator, middle  hemorrhoidal,  uterine,  vaginal,  internal  pudic 
and  sciatic.  From  posterior  trunk:  Ilio-lumbar,  gluteal,  lat- 
eral sacral. 


206  ANATOMY. 

Give  the  course  of  the  female  ureters. 

Rest  upon  psoas  magnus  muscles,  pass  over  brim  of  pelvis 
into  cavity  of  same  to  base  of  broad  ligaments,  then  l^  inch 
from  cervix  uteri,  laterally,  obliquely  forward  and  inward  in 
anterior  vaginal  wall  to  base  of  bladder. 

What  nerves  form  the  pharyngeal  plexus? 

Glosso-pharyngeal,  pneumogastrie  and  cervical  sympathetic. 

What  structures  are  severed  in  tracheotomy? 

Skin,  superficial  and  deep  cervical  fascia  and  trachea ;  per- 
haps anterior  jugular  vein,  or  branches,  and  thyroid  isthmus. 

Describe  the  phrenic  nerve. 

Is  formed  by  the  fourth  cervical  nerve,  chiefly,  passes  down- 
ward upon  anterior  surface  of  scalenus  anticus  muscle,  enters 
superior,  then  middle  mediastinum  and  perforates  diaphragm 
to  supply  its  under  surface. 

Describe  the  ulnar  artery  as  to  (a)  origin,  (b)  course, 
(c)   distribution. 

(a)  Is  one  of  terminal  branches  of  brachial;  (b)  is  be- 
neath superficial  flexors  of  forearm,  passes  obliquely  to  ulnar 
border,  having  ulnar  nerve  to  ulnar  side  of  it  for  lower  %  of 
its  extent,  then  curves  across  palm  near  lower  border  of  an- 
terior annular  ligament  (superficial  palmar  arch),  first  send- 
ing communicating  branch  to  deep  arch,  (c)  Is  distributed 
to  structures  around  internal  aspect  of  elbow,  to  ulnar  side 
of  forearm,  to  interosseous  membrane,  anteriorly  and  pos- 
teriorly, and  adjacent  muscles,  and  to  palm  and  flexor  sur- 
face of  fingers. 

How  are  the  saphenous  veins  formed?  Where  do  the 
saphenous  veins  empty? 

Internal  saphenous  is  formed  upon  dorsal  surface  of  foot 
and  inner  border;  external  saphenous  is  formed  upon  dor- 
sum and  outer  border  of  foot.  Internal  saphenous  vein 
empties  into  femoral  at  saphenous  opening  in  fascia  lata ;  ex- 
ternal saphenous  terminates  in  popliteal  vein. 


ANATOMY.  20T 

Give  the  situation  of  the  lymphatic  glands  of  the  thorax^ 

Intercostal  spaces  posteriorly,  anterior  and  posterior  medi- 
astina,  around  bronchial  tubes. 

Give  the  boundaries  and  mention  the  contents  of  the 
posterior  mediastinum. 

Is  bounded  in  front  by  pericardium  and  roots  of  lungs, 
behind  by  vertebral  column  and  on  either  side  by  pleura.  It 
contains  descending  thoracic  aorta,  greater  and  lesser  azygos 
veins,  pneumogastric  and  splanchnic  nerves,  esophagus,  thor- 
acic duct  and  lymphatic  glands. 

Describe  the  internal   abdominal   ring. 

Is  oval  in  shape,  long  axis  directed  vertically,  located  in 
transversalis  fascia  i/^  inch  above  Poupart's  ligament  and 
midway  between  anterior  superior  iliac  and  pubic  spines. 
Structures  of  spermatic  cord  pass  through  it  in  male,  round 
ligament  in  female.  Infundibuliform  fascia  is  attached  to  its 
margin ;  deep  epigastric  artery  courses  along  inner  margin. 

Give  a  method  by  which  the  fissures  of  Sylvius  and 
Rolando  may  be  approximately  mapped  out  on  the  sur- 
face of  the  skull. 

Fissure  of  Sylvius :  Draw  a  line  from  a  point  one  inch  and 
a  quarter  horizontally  behind  external  angular  process  of 
frontal  bone  to  a  point  %  of  an  inch  below  parietal  emi- 
nence. Fissue  of  Rolando :  From  a  point  I/2  inch  behind 
mid-point  of  line  between  glabella  and  external  occipital  pro- 
tuberance, draw  a  line  for  3%  inches  over  side  of  head  at 
angle  of  67°  with  median  line. 

Locate  and  describe  Peyer's  glands. 

Are  located  in  wall  of  ilium,  more  numerous  at  lower 
part;  are  more  or  less  oval  bodies  collected  together;  con- 
sist of  adenoid  (lymphoid)  tissue. 

Describe  the  tonsils  and  name  some  of  the  arteries 
which  supply  them  with  blood. 

.\n'  placed  hi'twocn  iinh-rioc  iiiid  i)osterior  palatine  arches^ 


208  ANATOMY. 

in  tonsillar  recess,  close  to  base  of  tongue,  vary  greatly  in 
size  and  shape,  surface  is  irregular  and  marked  by  numerous 
depressions  leading  into  crypts  in  substance  of  tonsil,  and 
are  surrounded  by  closed  follicles  of  lymphoid  tissue.  Ar- 
teries :  Dorsalis  linguae,  ascending  palatine  and  tonsillar  of 
facial,  descending  palatine  of  internal  maxillary,  ascending 
pharyngeal. 

Describe  the  male  urethra  and  state  its  divisions. 

Divided  into  prostatic,  membranous  and  spongy  portions; 
prostatic  passes  through  prostate  gland,  has  veru  montanum 
and  orifices  of  ejaeulatory  ducts  in  its  floor,  upon  either  side 
of  which  are  prostatic  sinuses  with  orifices  of  prostatic  glands ; 
membranous  portion  is  shortest  of  the  three,  is  contained  be- 
tween the  two  layers  of  triangular  ligament,  and  surrounded 
by  compressor  urethrse  muscle;  spongy  portion  is  contained 
in  corpus  spongiosum,  terminates  at  meatus  urinarius  exter- 
nus  (least  dilatable  part  of  urethra)  and  has  several  depres- 
sions in  mucous  membrane  of  roof,  largest  of  which,  just 
behind  fossa  navicularis.  which  is  close  to  meatus,  is  named 
lacuna  magna. 

What  is  the  origin  and  course  of  the  pulnronary  artery? 

Origin  is  from  right  ventricle ;  course  is  upward  and 
slightly  to  left  to  under  surface  of  transverse  portion  of 
aortic  arch,  where  it  divides  into  right  and  left  pulmonary 
arteries  for  right  and  left  lungs  respectively. 

Give  the  names  of  the  principal  muscles  of  the  back. 

Trapezius,  latissimus  dorsi,  rhomboideus  major  and  minor, 
erector  spinse. 

Locate  and  describe  the  rectum. 

Extends  from  third  piece  of  sacrum  to  anus,  with  forward 
curve,  is  covered  by  peritoneum  in  front  and  on  the  sides 
only;  longitudinal  and  circular  muscular  fibers  pronounced; 
mucous  membrane  thick,  presenting  several  permanent,  trans- 
verse folds,  plicae  recti,  or  valves  of  Houston;  is  supplied  by 


ANATOMY.  209 

superior,   middle  and  inferior  hemorrhoidal  arteries;  is  be- 
hind bladder  and  prostate  in  male  and  vagina  in  female. 

Where  does  the  abdominal  aorta  commence  and  where 
does  it  terminate? 

Commences  at  aortic  opening  in  diaphragm  upon  body  of 
twelfth  thoracic  vertebra;  terminates  upon  body  of  fourth 
lumbar  vertebra,  just  to  left  of  median  line. 

Where  is  the  foramen  ovale  of  the  heart  and  what 
purpose  does  it  serve? 

In  the  wall  between  the  auricles ;  permits  passage  of  blood 
in  the  foetus  from  right  to  left  auricle,  deflecting  its  course 
from  right  ventricle  and  pulmonary  circulation  into  general 
•circulation. 

What  are  the  lymphatic  glands? 

Parts  of  lymphatic  system  consisting  of  adenoid  tissue, 
•enclosed  in  capsule,  having  afferent  and  efferent  lymphatic 
vessels;  lymph  passes  through  them. 

Describe  the  changes  in  the  vascular  system  at  birth. 

Blood  ceases  to  flow  through  umbilical  vein  and  ductus 
venosus  into  inferior  cava ;  hypogastric  arteries  become  ob- 
literated :  foramen  ovale  closes  and  blood  then  does  not  pass 
from  right  to  left  auricle;  ductus  arteriosus,  connecting  pul- 
monary artery  with  arch  of  aorta  becomes  impervious  and 
pulmonary  circulation  is  actively  established. 

In  the  anatomy  of  the  brain  what  is  the  corpus  callo- 
sum?     Describe  its  connections. 

The  great  transverse  commissure  consisting  of  fibers  which 
pass  from  one  hemisphere  to  the  other,  connecting  different 
parts  of  the  cortex  of  one  with  that  of  the  other,  is  located 
nearer  the  base  than  the  top  and  forms  the  roof  of  the  lateral 
ventricles. 

Mention  a  muscle  (a)  which  moves  the  thumb  outward, 

U 


210  ANATOMY. 

(b)  which  moves  the  head  forward,  (c)  which  moves  the 
foot  inward. 

(a)  Abductor  pollicis;  (b)  sterno-cleido-mastoid  (rectus 
capitis  anticus  major)  ;    (c)   tibialis  anticus. 

What  is  the  composition  of  intervertebral  substance? 
How  much  of  the  spinal  column  does  this  substance  form? 

Is  made  up  of  fibro-cartilage ;  constitutes  about  i/4  of  the 
spinal  column. 

Give  the  boundaries  of  the  anterior  mediastinum. 

In  front  by  the  sternum,  behind  by  the  pericardium,  later- 
ally by  the  pleura?. 

What  are  the  ciliary  processes  in  the  eye?  Where  are 
they  placed  and  what  is  their  average  number? 

Folds  of  middle  tunic  (uveal  tract)  consisting  of  connec- 
tive tissue,  blood-vessels  and  pigment;  are  placed  around  per- 
iphery of  lens  close  to  edge,  posteriorly,  and  number  about 
seventy. 

State  the  action  of  each  of  the  following  muscles:  mas° 
seter,  tibialis  anticus,  gluteus  maximus. 

Masseter,  to  bring  lower  jaw  ,up  against  upper  jaw;  tibialis 
anticus,  to  tiex  foot  upon  leg  and  elevate  and  adduct  inner 
border  of  foot;  gluteus  maximus,  to  extend  trunk  upon  thigh, 
or  thigh  upon  trunk. 

Describe  the  structure  of  the  spleen. 

The  interior  is  divided  into  lobules  1  mm.  in  diameter,  con- 
taining a  vascular  lymphoid  tissue,  the  splenic  pulp.  Within 
these  collections  course  the  terminal  arterioles  of  the  splenic 
artery,  surrounded  by  accumulations  of  lymphoid  tissue,  the 
malpighian  bodies,  while  venous  spaces  (intralobular  veins) 
are  found  around  them.  There  is  no  capillary  stage  to  these 
vessels. 

The  pulp  cells  consist  of  leucocytes  of  different  types,  red 
blood  cells  and  giant  cells  with  large  nuclei.  A  variable 
amount  of  free  pigment  is  also  present,  probably  from  the 
broken-down  red  blood  cells. 


ANATOMY.  211 

Name  the  muscles  controling  the  elbow  joint  and  give 
their  origin  and  insertion. 

Biceps  flexor  cubiti.  Origin :  long  head  from  upper  mar- 
gin of  glenoid  fossa,  short  head  from  eoracoid  process;  in- 
sertion into  bicipital  tuberosity  of  radius. 

Triceps  extensor  cubiti.  Origin:  long  head  from  axillary 
border  of  capula  below  glenoid  fossa,  humeral,  heads  from 
shaft  of  humerus  above  and  below  musculo-spiral  groove ;  in- 
sertion into  olecranon  process. 

Braehialis  anticus.  Origin:  anterior  surface  lower  half  of 
shaft  of  humerus;  insertion  into  eoronoid  process  of  ulna. 

Describe  Scarpa's  triangle  and  name  the  structures  con» 
tained  therein. 

Base  of  triangle  formed  by  Poupart's  ligament,  outer  leg 
by  sartorius,  inner  leg  by  adductor  longus,  floor  by  ilio-psoas 
and  pectineus. 

Sutures  contained  therein  are  common  femoral  artery,  deep 
and  superficial  femoral  arteries,  femoral  and  long  saphenous 
v^eins,  anterior  crural  and  external  cutaneous  nerves. 

Give  the  structure,  blood  supply  and  nerve  supply  of  the 
uterus. 

Structure,  unstriped  muscle,  arranged  chiefly  longitudi- 
nally and  circularly;  body  covered  externally  by  peritoneum; 
body  and  cervix  lined  by  raucous  membrane  possessing  colum- 
nar ciliated  epithelial  cells,  partly  ciliated. 

Blood  supply  is  from  uterine  arteries,  branches  of  internal 
iliac,  which  anastomose  with  each  other  and  with  ovarian 
arteries. 

Nerve  supply  is  through  utero-vaginal  plexus  of  sympa- 
thetic system,  and  also  from  second,  third  and  fourth  sacral 
spinal  nerves. 

Name  and  describe  the  ligaments  of  the  knee  joint. 

Capsule,  composed  of  ligamentum  patelhi;  anteriorly,  apo- 
neurosis of  vastus  externus  and  vastus  internus  antero- 
latci-ally,  posterior  ligament  posteriorly,  internal  and  exter- 
nal lateral  ligaments  laterally. 


212  ANATOMY. 

Internally,  two  crucial  ligaments  and  two  semilunar  inter- 
articular  cartilages. 

Ligamentum  patellae  continues  insertion  of  rectus  femoris 
to  tibia;  posterior  ligament  is  strengthened  by  reflections  of 
semimembranosus  tendon  of  insertion;  internal  lateral  liga- 
ment from  internal  condyle  of  femur  to  inner  tuberosity  of 
tibia,  is  attached  to  inner  semilunar  cartilage ;  external  lateral 
ligament  from  outer  condyle  of  femur  to  head  and  styloid 
process  of  fibula;  internal  and  external  crucial  ligaments  are 
stout,  robust  bands  extending  between  upper  end  of  tibia 
and  sides  of  intercondyloid  notch  of  femur;  semilunar  car- 
tilages are  closely  attached  to  non-articular  area  at  base  of 
spine  on  upper  end  of  tibia,  and  are  flat  underneath  and 
concave  on  upper  surface. 

Name  the  arteries  of  supply  and  distribution  of  the 
circle  of  Willis. 

Two  internal  carotids  and  two  posterior  cerebrals,  united 
by  two  posterior  communicating  arteries,  and  two  anterior 
cerebrals  united  by  anterior  communicating  artery;  branches 
of  distribution  are  antero-median  and  antero-lateral,  postero- 
median and  postero-lateral  ganglionic  branches. 

Give  the  distribution  of  the  pneumogastric  nerve. 

To  back  of  auricle,  to  pharynx,  to  larynx,  to  heart,  to 
lungs,  to  esophagus,  to  stomach,  to  spleen,  pancreas,  intestine, 
suprarenal  bodies,  kidneys  and  liver. 

Locate  the  fissure  of  Sylvius  and  the  fissure  of  Rolando 
on  the  surface  of  the  cerebrum. 

Fissure  of  Sylvius  commences  at  anterior  perforated  spot 
on  under  surface  of  cerebrum,  curves  outward,  upward  and 
backward  between  frontal  and  temporal  and  between  pari- 
etal and  temporal  lobes. 

Fissure  of  Rolando  commences  at  the  great  longitudinal 
fissure  just  back  of  its  mid-point  and  extends  forward  and 
outward  for  3%  inches  at  an  angle  of  71.7°  with  great  lon- 
gitudinal fissure. 


PHYSIOLOGY. 


What  structures  register  the  sensations  of  light?  De= 
scribe  the  retina. 

The  layer  of  rods  and  cones  in  the  retina. 

The  retina  is  the  innermost  and  nervous  coat  of  the  eye. 
It  is  cup-shaped  and  gives  origin  to  the  optic  nerve  to  the 
inner  side  of  its  center  posteriorly.  It  is  composed  of  8  to 
10  layers  of  which  the  layer  of  rods  and  cones  and  the  pig- 
ment layer  are  the  most  important. 

What  is  tactile  sense?  Mention  the  four  most  sensitive 
areas  of  the  body. 

Tactile  sense  is  the  sense  of  touch.  The  sensitiveness  of  a 
part  is  tested  by  an  aesthesiometer,  an  instrument  similar  to 
a  pair  of  calipers.  It  is  used  by  placing  the  two  points  on 
the  part  to  be  examined  and  determining  the  shortest  separa- 
tion giving  the  sensation  of  two  points. 

Tip  of  the  tongue,  1  Mm.  Tip  of  the  forefinger,  2  Mm. 
Other  fingers,  4  Mm.    Palm  of  hand,  10  Mm.     (Weber.) 

Describe  a  method  of  determining  the  direction  of  nerve 
fibres  in  the  columns  or  tracts  of  the  spinal  cord. 

Degeneration  method — consisting  of  sectioning  of  the  cord 
or  a  part  of  the  cord  and  then  waiting  for  degeneration  to 
take  place.  The  ascending  tracts  having  their  trophic  cen- 
ters in  the  posterior  root  ganglion,  their  fibres  will  degenerate 
above  the  point  of  section.  The  descending  tracts  having 
their  trophic  centers  higher  up,  mostly  in  the  cortex,  de- 
generate below  the  point  of  section. 

(213) 


214  PHYSIOLOGY. 

Explain  the  relation  of  the  internal  capsule  to  hemi= 
plegia. 

The  internal  capsule  is  composed  of  the  sensory  and  motor 
tracts  connecting  the  cortex  with  the  other  parts  of  the  ner- 
vous system  and  the  body.  Its  blood  supply  is  through  non- 
anastomosing  arteries.  An  embolus  or  a  hemorrhage  into  the 
capsule  will  interfere  with  its  functional  activity  with  the 
resulting  hemiplegia. 

What  physiologic  arguments  can  be  advanced  against  a 
continuous  adherence  to  a  non=nitrogenous  diet? 

In  the  physiologic  activities  of  the  tissues  there  is  a  certain 
amount  of  nitrogenous  waste  which  must  be  replaced.  This 
can  be  obtained  only  from  nitrogenous  foods. 

Describe  the  function  of  the  nose  in  respiration.  State 
causes  and  results  of  mouth  breathing. 

In  respiration  the  Schneiderian  mucous  membrane  of  the 
nose,  warms  and  moistens  the  air  by  reason  of  its  vascularity, 
the  turbinates  by  their  shape  mix  the  air  and  moisture,  the 
hairs  filter  the  air. 

The  causes  of  mouth  breathing  are  catarrhs,  or  tumors, 
like  polyps,  adenoids,  or  deformities  of  the  nasal  wall  which 
obstruct  the  nose.    In  a  few  cases  it  may  be  due  to  habit. 

The  results  of  mouth  breathing  are  laryngitis,  trachitis, 
bronchitis,  or  pneumonitis.  Secondarily  in  growing  children 
the  facial  expression  is  permanently  altered. 

What  are  the  principal  functions  of  the  posterior,  la= 
teral,  and  anterior  columns  of  the  spinal  cord? 

The  posterior  columns  are  concerned  in  conducting  tactile 
sensations.  The  lateral  columns  contain  motor  fibres 
(crossed  pyranjidal  tract),  ascending  and  descending  cere- 
bellar tracts,  and  commissural  fibres.  The  anterior  columns 
are  partly  motor  (direct  pyramidal  tract)   and  commisural. 

Describe  the  uses  of  adipose  tissue. 

Adipose  tissue  protects  the  body  from  heat  and  cold  by 


PHYSIOLOGY.  215 

reason  of  it  being  a  poor  conductor.    It  is  also  a  storage  place 
for  fats  used  for  heat  and  energy. 

Explain  the  physiologic  mechanism  involved  in  a  chill. 

The  cold  refiexly  sets  up  involuntary  contractions  of  the 
voluntary  muscles  of  the  body  causing  the  generation  of  more 
heat  within  the  body. 

In  what  marked  particular  does  living  matter  differ  from 
lifeless  matter?     What  is  metabolism? 

Living  matter  has  five  characteristics  distinguishing  it  from 
lifeless  matter,  viz.,  Motion,  Sensibility,  Keproduction,  Nu- 
trition, and  Evolution.  Metabolism  is  the  exchange  of  ma- 
terials in  the  tissues.  It  consists  of  anabolism,  or  upbuilding, 
and  catabolism,  or  tearing  down  of  the  tissues. 

How  is  the  diaphragm  affected  in  expiration?  State 
the  cause. 

In  expiration  the  diaphragm  relaxes,  becoming  more  dome- 
shaped.  Its  central  part  rises  into  the  thorax,  decreasing  the 
vertical  diameter  of  the  thoracic  cavity. 

How  and  where  do  the  various  types  of  foods  when 
digested  enter  the  blood? 

'  The  proteids  being  reduced  to  peptones  enter  the  villi  and 
are  converted  into  serum  albumen  and  serum  globulin  by  the 
vital  activity  of  the  striated  columnar  epithelium  of  the  villi ; 
these  are  taken  up  by  the  capillaries  of  the  villi  and  then 
carried  by  the  portal  vein  to  the  liver.  The  carbohydrates 
being  reduced  to  glucoses  enter  the  villi,  are  taken  up  by  the 
capillaries  and  then  by  the  portal  vein  to  the  liver.  Here  a 
greater  part  is  stored  as  glycogen  until  needed  by  the  tissues. 
The  excess  passes  through  the  hepatic  vein  to  the  circulation 
and  is  excreted  by  the  kidneys.  The  fats  are  reduced  to  fatty 
a-cids  and  glycerin,  i)ass  into  the  villi,  are  rebuilt  into  neu- 
tral fat.s  by  the  vital  activities  of  the  striated  coluinnar  epi- 
thelium of  the  villi.  They  enter  the  lacteals  uniting  with 
]yiii{)h  to  form  chyle  and  thence  to  the  receptaeulum-chyli 
and  thoracic  duct  to  empty  into  the  left  subclavian  vein. 


216  PHYSIOLOGY. 

Into  what  four  classes  are  foodstuffs  commonly  divided? 
Give  an  example  of  one  food  belonging  to  each  class. 

Proteids  :  meats.  Carbohydrates :  starches  or  sugar.  Fats  r 
butter.    Accessory  foods:  tea,  coffee,  etc. 

Describe  the  bile=producing  and  the  glycogenic  function 
of  the  liver. 

Bile  is  produced  by  the  activity  of  the  liver  cells  chiefly 
from  the  blood  from  the  portal  vein.  It  is  collected  in  little 
canals  hollowed  between  the  cells  and  emptied  into  the  bile 
capillaries.  Through  these  it  is  forced  on  into  the  bile  duct 
and  either  passed  on  into  the  duodenum  during  the  act  of 
digestion,  or  stored  in  the  gall  bladder  until  needed. 

Glycogen  or  animal  starch  is  formed  by  the  protoplasmic- 
activity  of  the  liver  cells  from  proteids  and  carbohydrates. 
It  is  deposited  in  the  liver  cells  and  when  needed  is  changed 
into  dextrose  by  a  diastatic  ferment  found  in  the  blood  of 
the  liver.  This  dextrose  is  carried  out  in  the  blood  of  the 
hepatic  vein  into  the  general  circulation. 

Give  a  dietary  for  people  beyond  the  age  of  sixty  years. 

Food  for  the  aged  should  be  readily  digestible  and  capable 
of  being  easily  burned  up  for  the  maintenance  of  the  heat 
of  the  body.  Among  suitable  articles  are  eggs,  milk,  rice,, 
properly  cooked  beef,  butter  and  bread. 

What  is  the  function  of  the  cerebellum? 

The  function  of  the  cerebellum  is  in  securing  the  co-ordina- 
tion of  muscular  movements. 

Describe  ciliated  epithelium  and  state  where  it  is  found 
most  abundantly. 

The  cells  of  ciliated  epithelium  are  generally  columnar  in 
shape  with  numerous  fine  filaments  projecting  from  their  free 
surface.  Ciliated  epithelium  is  found  most  abundantly  in  the 
trachea  and  bronchi  and  here  sweeps  the  mucus  and  small 
dirt  particles  toward  the  mouth. 


PHYSIOLOGY.  21T 

Give  a  description  of  the  act  of  deglutition  and  mention 
the  muscles  brought  into  action  in  swallowing. 

The  swallowing  of  solids  is  divided  into  three  stages — 
buccal,  pharyngeal,  and  esophageal.  The  first  is  voluntary, 
the  others  involuntary.  The  food  is  formed  into  a  bolus  and 
pressed  backward  by  the  tongue  into  the  pharynx;  the  nasal 
cavities  being  closed,  the  pharyngeal  muscles  contract  and 
force  it  on  dow^n  to  the  esophagus.  This  in  turn  contracts 
and  by  a  peristaltic  movement  forces  the  bolus  into  the- 
stomach. 

Liquids  are  not  swallowed  in  this  way,  but  are  squirted 
down  the  esophagus,  with  a  bulb  syringe  effect,  by  the 
mylohyoid  muscle.  The  muscles  involved  in  deglutition  are 
the  mylohyoid,  muscles  of  the  tongue,  pharyngeal  muscles, 
especially  the  constrictors  and  the  involuntary  muscular 
fibers  of  the  esophagus. 

How  is  asphyxia  produced?  What  are  the  causes  of 
death  from  asphyxia? 

It  is  produced  by  anything  causing  a  deficiency  in  the 
supply  of  oxygen  to  the  tissues,  as  edema  of  lungs,  membran- 
ous laryngitis,  constriction  of  the  trachea. 

Death  is  caused  by  a  deficiency  in  the  amount  of  oxygen 
and  the  accumulation  of  carbon  dioxide  in  the  blood.  The 
respiratory  center  is  probably  the  first  one  to  be  disabled. 

Describe  (a)  chyme,  (b)  chyle. 

Chyme  is  the  acid  semi-fluid  mass  of  partially  digested  food 
passing  from  the  stomach  into  the  duodenum. 

Chyle  is  the  lymph  found  in  the  lacteals  of  the  intestines 
containing  the  absorbed  fat.  It  is  a  milky  w^hite.  alkaline 
fluid. 

Give  the  process  of  coagulation  of  blood. 

The  fibrin  ferment  formed  by  the  disintegration  of  the 
white  corpuscles  acts  upon  the  fibrinogen  and  converts  it,  if 
calcium  salts  are  present,  into  the  insoluble  fibrin.  The 
fibrin    is    formed    in   little    filaments   all   through    the   blood 


218  PHYSIOLOGY. 

and  immeshes  the  blood  corpuscles.  This  forms  the  clot 
which  g'radually  begins  to  contract.  A  liquid  called  serum 
soon  exudes  and  collects  over  the  clot. 

Name  the  functions  of  the  chorda  tympani,  sufficiently 
detailing  each  to  clearly  define  its  character. 

The  chorda  tympani  contains  the  vasodilator  fibers,  but 
no  vasoconstrictor  fibers,  for  the  anterior  tongue  and  sub- 
maxillary gland.  It  contains  the  secretory  fibers  to  the  sub- 
maxillary gland,  and  also  the  taste  fibers  for  the  anterior 
two-thirds  of  the  tongue. 

Name  the  groups  of  food  stuffs  constituting  the  source 
of  muscular  energy.  Designate  the  most  important  and 
state  what  stored  product  is  utilized. 

Carbohydrates  are  the  most  important,  but  fats  and  pro- 
teids  may  be  used  in  the  production  of  muscular  energy. 
Glycogen  is  the  stored  product  that  is  utilized. 

State  the  function  of  the  nervus  opticus,  and  explain  by 
description  or  diagram  the  distribution  of  the  fibers  com= 
posing  the  chiasma  and  the  effect  thereof  upon  vision. 

The  nervus  opticus  is  the  nerve  of  the  special  sense,  sight. 

At  the  chiasma,  the  inner  half  of  each  optic  nerve  crosses 
to  the  opposite  side ;  therefore,  in  loss  of  function  of  one  optic 
nerve  from  injury  or  pressure  back  of  the  chiasma,  there  is 
blindness  of  the  temporal  side  of  retina  of  the  same  eye  and 
of  the  nasal  side  of  opposite  eye.  Stimulation  of  one  retina 
by  light  causes  a  reflex  contraction  of  both  pupils. 

Describe  metabolism. 

Metabolism  is  the  chemical  change  going  on  in  organized 
tissue.  There  are  two  divisions — anabolism  or  building  up, 
and  katabolism  or  tearing  down.  This  chemical  change  is 
usually  a  hydration,  dehydration,  reduction  or  oxidation. 

In  the  metabolism  of  proteids  of  the  tissue,  proteid  food 
must  be  used  to  repair  the  loss. 

The  carbohydrates  are  the  substances  most  readily  broken 
up  to  supply  heat  and  energy,  the  fats  being  next  in  order. 


PHYSIOLOGY.  219 

The  salts  are  needed  in  the  various  processes,  but  especially 
to  combine  with  the  acids,  sulphuric  and  phosphoric,  formed 
in  proteid  katabolism. 

What  is  the  normal  proportion  of  blood  in  the  human 
body  and  how  is  it  renewed  after  hemorrhage? 

About  one-thirteenth  of  the  body  weight  is  blood.  The 
water  and  other  constituents  of  plasma  are  renewed  from  the 
ingested  food.  The  corpuscles  are  renewed  by  the  bone  mar- 
row, spleen  and  lymphatic  tissues. 

State  the  effects  of  battery  currents  on  the  normal 
human  nerves. 

The  faradic  current  stimulates  them. 

A  nerve  during  the  passage  of  a  constant  current  through 
it,  is  said  to  be  in  a  state  of  electrotonus.  There  is  an  in- 
crease of  excitability  at  the  negative  pole  or  kathode,  and 
decrease  of  excitability  at  the  positive  or  anode. 

Give  the  relative  food  value  and  ease  of  digestion  of 
meat,  milk,  eggs,  leguminous  fruits. 

According  to  relative  food  value  the  order  is — meat,  eggs, 
milk  and  leguminous  fruits. 

According  to  relative  ease  of  digestion  the  order  is  milk, 
eggs,  meat  and  leguminous  fruits. 

What  are  the  effects  of  removal  of  the  cerebrum  in  the 
lower  animals? 

A  decerebrated  animal  loses  all  power  of  voluiitai-y  move- 
ment, remaining  (juiescent  until  some  external  stimulus  brings 
out  a  reflex  movement.  Thus,  food  may  be  placetl  before 
him,  but  he  will  not  take  it;  if  it  is  placed  in  his  mouth,  he 
will  swallow  it.  If  turned  on  his  back,  he  will  right  him- 
self,    lie  .shows  no  fear. 

What  conditions  are  necessary  for  properly  exercising 
the  sense  of  smell? 

For  the  proper  exercise  of  the  sense  of  smell,  the  sub- 
stance must  be  volatile,  the  air  in  the  nasal  cavity  must  be 


220  PHYSIOLOGY. 

in  motion,  and  the  olfactory  apparatus  must  be  in  normal 
condition. 

How  would  digestion  be  affected  were  the  ductus  coni= 
munis  choledochus  obstructed? 

In  obstruction  of  the  ductus  communis  choledochus  the 
feces  contain  large  quantities  of  undigested  fats,  the  stools 
become  hard  and  fetid,  and  finally  death  ensues  from  ab- 
sorption of  putrefactive  products  from  the  intestines. 

Give  the  mechanism  of  the  diaphragm  in  (a)  respiration, 
(b)  hiccough. 

During  rest  or  relaxation  the  diaphragm  is  domed  upward. 
During  inspiration,  the  muscle  contracts,  the  central  tendon  is 
pulled  down  and  thus  the  vertical  diameter  of  the  thorax  is 
increased.  During  expiration,  the  muscle  relaxes  and  the 
diaphragm  resumes  its  domed  position. 

Hiccough  is  caused  by  a  sudden  spasmodic  contraction  of 
the  diaphragm,  the  inspiration  thus  caused  being  arrested 
by  a  sudden  closure  of  the  glottis. 

How  does  the  nervous  system  influence  gastric  diges= 
tion? 

Through  the  vagus  the  secretion  of  the  stomach  is  con- 
trolled from  the  central  nervous  system.  The  vasomotor 
nerves  of  the  stomach  also  influence  secretion  by  controlling 
the  mount  of  blood  to  the  stomach. 

Give  the  physiology  of  (a)  hunger,  (b)  thirst. 

Hunger  is  the  constitutional  need  of  the  body  for  food 
with  the  eccentric  symptoms  in  the  epigastrium.  The  im- 
poverishment and  changes  in  the  blood  so  affect  the  central 
nervous  system  as  to  cause  the  sensation. 

Thirst  is  the  constitutional  need  of  the  body  for  water 
with  the  eccentric  symptom  in  the  pharynx.  The  lack  of 
water  in  the  blood  so  affects  the  nervous  system  as  to  cause 
this  dryness  of  the  throat. 


PHYSIOLOGY.  221 

Give  the  foramen  of  exit,  the  distribution  and  the  func> 
tion  of  the  pathetic  (fourth  cranial)  nerve. 

The  pathetic  or  trochlear  nerve  passes  out  through  the 
sphenoidal  fissure  and  is  the  motor  nerve  of  the  superior 
oblique. 

Give  the  process  of  development  of  the  parietal  bone. 

The  parietal  bone  is  formed  between  membranes  and  is  not 
preceded  by  temporary  cartilage 

The  membrane  is  formed  of  an  external  fibrous  layer  and 
an  internal  layer,  which  becomes  the  periosteum  and  consists 
of  a  layer  of  osteoblasts. 

Starting  from  a  point  called  the  center  of  ossification,  little 
spicules  of  bone  are  deposited  in  all  directions  in  the  inter- 
cellular substances.  As  they  become  more  numerous,  they 
completely  enclose  the  osteoblasts,  which  remain  permanently 
in  the  bone.  This  process  spreads  in  all  directions  and  thus 
the  bone  is  formed. 

Explain  the  physiological  circuit  essential  to  a  reflex 
action. 

The  essentials  are  an  afferent  nerve,  a  nerve  center,  an 
efferent  nerve  and  the  peripheral  organ  which  it  supplies. 

Mechanical  irritation  of  the  sensory  fibers  of  the  vagus  in 
the  mucous  membrane  of  the  stomach  causes  an  increased 
flow  of  saliva  by  irritation'  of  the  salivary  center  in  the 
medulla  and  consequent  passage  of  efferent  impulses  to  the 
salivary  glands. 

What  is  the  function  of  the  sixth  (abducens)  nerve? 

The  abducens  is  the  motor  nerve  of  the  external  rectus. 

Describe  the  respiratory  function  of  the  red  blood  cor- 
puscles. 

When  the  venous  blood  reaches  the  capillaries  sur- 
rounding the  air  vesicles  of  the  lung,  the  hemoglobin  found 
in  the  red  corpuscles  rapidly  combines  with  the  absorbed 
oxygen  to  form  oxyhemoglobin.  This  is  carrie<l  back  to  the 
heart  and  then  into  the  systemic  circulation,  finally  reaching 


222  PHYSIOLOGY. 

the  capillaries.  Here  the  tissues  take  the  oxygen  from  the 
loosely  combined  oxyhemoglobin.  The  hemoglobin  is  then 
carried  back  to  the  lungs  to  be  reoxygenated.  The  cor- 
puscles also  carry  small  amounts  of  carbon  dioxide  from  the 
tissues  to  the  lungs. 

Describe  the  normal  pulse;  state  the  factors  active  in 
its  maintenance,  and  give  the  average  rate  during  infancy^ 
youth  and  adult  age. 

The  pulse  is  the  transmission  of  the  cardiac  impulse 
throughout  the  arterial  system.  A  normal  pulse  should  be 
full,  of  moderate  tension,  regular  and  of  the  right  frequency. 
It  is  ordinarily  examined  over  the  radial  artery  at  the  wrist, 
because  in  this  position  there  is  a  hard  surface  against  which 
we  can  press  the  artery. 

The  factors  active  in  its  maintenance  are  the  normal  action 
of  the  heart  and  of  the  vasomotor  system. 

The  average  rate  during  infancy  is  130  to  140;  during 
youth  80  to  90 ;  during  adult  life  70  to  75. 

Name  the  active  principles  of  the  digestive  secretions 
and  state  how  each  affects  the  food. 

Ptyalin  of  saliva  changes  starch  into  maltose. 

Pepsin,  when  hydroehloric  acid  is  present,  changes  proteids. 
into  proteoses  and  peptones. 

Rennin  changes  caseinogen  into  casein. 

Amylopsin  changes  starch  into  maltose,  dextrose,  and  dex- 
trin. 

Steapsin  splits  up  fat  into  fatty  acid  and  glycerin. 

Trypsin,  in  an  alkaline  medium,  changes  proteids  into 
proteoses  and  peptones. 

Invertin  changes  maltose  into  dextrose,  and  saccharose 
into  equal  parts  of  dextrose  and  levulose. 

Bile  contains  no  ferment,  but  aids  the  pancreatic  secretion 
in  the  emulsification  of  fats. 

From  what  portions  of  the  cortex  cerebri  do  the  arm^ 
face  and  leg  receive  their  motor  impulses? 

The  motor  area  is  along  the  fissure  of  Rolando  in  the  as- 


PHYSIOLOGY.  223 

cending  frontal,  ascending  parietal  and  paracentral  convolu- 
tions. The  leg  center  is  the  uppermost,  the  arm  center  next, 
and  the  face  center  the  lowermost. 

Describe  the  position  of  the  vocal  chords  during  phona= 
tion  and  name  the  factors  concerned. 

The  chink  of  the  glottis  during  phonation  is  narrowed, 
the  arytenoid  cartilages  are  approximated  and  the  vocal  cords 
are  stretched.  The  arytenoid  muscle  approximates  the  ary- 
tenoid cartilages,  and  with  the  help  of  the  lateral  crico-ary- 
tenoids  and  the  internal  part  of  the  thyro-arytenoids  closes 
the  glottis.  The  vocal  cords  are  made  tense  by  the  crico- 
thyroids and  external  part  of  the  thyro-arytenoids. 

Give  the  origin  of  normal  fat  in  the  human  body  and 
name  examples  of  the  types  of  food  from  which  it  is 
elaborated. 

The  normal  fat  of  the  body  is  derived  from  food  ingested. 
Any  excess  of  food  is  stored  up  as  fat.  Fat  may  be  elabor- 
ated from  fats  ingested  as  olein,  from  carbohydrates  as  starch, 
or  from  proteids  as  casein. 

Describe  a  complete  physiological  revolution  of  the 
heart. 

During  diastole  the  blood  from  the  auricles  passes  into 
the  ventricles.  Toward  the  end  of  diastole  the  auricles 
contract,  forcing  the  blood  remaining  in  them  into  their 
respective  ventricles ;  the  ventricles  now  contract,  the  auriculo- 
ventricular  valves  are  closed  and  the  blood  is  forced  into  the 
pulmonary  artery  and  aorta  through  the  open  semilunar 
valves ;  the  ventricles  now  relax,  the  semilunar  valves  clos- 
ing with  a  snap  and  the  auriculo-ventricular  valves  being 
opened  by  the  force  of  blood  in  the  auricles  and  by  the  nega- 
tive pressure  in  the  ventricles. 

If  the  cardiac  revolution  were  divided  into  tenths,  the  first 
or  systolic  sound  would  occupy  four-tenths,  the  short  silence 
one-tenth,  the  second  or  dia.stolic  sound  two-tenths,  and  the 
long  silence  three-tenths. 


224:  PHYSIOLOGY. 

Describe  the  process  of  respiration. 

Eespiration  is  the  function  of  taking  in  oxygen  and  the 
throwing  off  cai^bon  dioxide.  This  exchange  of  gases  takes 
place  in  the  air  vesicles  where  the  blood  and  atmospheric  air 
are  separated  by  but  a  single  layer  of  squamous  epithelium. 

Three  factors  are  concerned  in  this  exchange — the  lajw  of 
pressure  of  gases,  chemical  affinity,  and  the  vital  activity 
of  the  epithelium. 

In  tissue  respiration  the  oxygen  passes  through  the  endo- 
thelium forming  the  capillary  wall,  into  the  tissue,  where  it  is 
used  up.  The  carbon  dioxide  there  formed  passes  from  the 
tissues  into  the  capillaries  and  thence  to  the  lungs. 

What  are  the  functions  of  the  bIood=vesseIs? 

Through  the  blood-vessels  the  blood  is  forced  to  the  various 
parts  of  the  body,  carrying  nutritive  products  to  the  tissues 
and  waste  from  the  tissues  to  the  organs  that  excrete  it.  By 
their  muscular  wall  they  regulate  the  amount  of  blood  going 
to  various  portions  of  the  body,  and  together  with  the  elastic 
tissue  they  contain  also  reduce  the  amount  of  work  thrown  on 
the  heart.  Through  the  capillary  wall  osmosis  and  diapedesis 
take  place. 

Name  and  describe  the  normal  respiratory  sounds  of  the 
lungs  and  bronchi. 

The  vesicular  sound  is  a  distant,  soft,  breezy  sound,  of 
low  pitch,  with  the  inspiration  three  or  four  times  longer 
than  expiration.  It  is  caused  by  air  passing  through  the 
bronchi,  the  sound  being  modified  by  the  air  vesicles.  The 
bronchial  sound  is  caused  by  the  air  rushing  in  and  out  of 
the  bronchi.  It  is  high  pitched,  loud,  tubular  in  quality,  the 
expiration  being  to  inspiration  as  seven  is  to  six. 

Of  the  functions  of  vision,  what  is  understood  by  ac= 
commodation? 

By  accomodation  is  meant  the  increasing  of  the  curvature 
of  the  anterior  surface  of  the  crystalline  lens  to  focus  near 
objects  on  the  retina. 


PHYSIOLOGY.  225 

Describe  the  action  of  the  kidneys,  and  give  the  normal 
constituents  of  the  urine. 

The  kidneys  are  compoimd  tubular  glands  that  pick  out 
from  the  blood  certain  waste  material  which  passes  down  the 
tubules  into  the  pelvis  of  the  kidneys  and  then  into  the 
bladder. 

But  one  constituent  of  the  urine  is  formed  in  the  kidney 
and  that  is  hippuric  acid. 

The  water  filters  through  the  glomeruli  principally,  while 
the  urea  is  picked  out  by  the  rodded  epithelium  of  the  con- 
voluted tubules.  No  proper  secretory  nerves  have  as  yet  been 
found  for  the  kidneys,  which  seem  rather  to  be  controlled  by 
the  vasomotor  system.  The  kidneys  have  possibly  an  internal 
secretion  also. 

The  normal  constituents  of  the  urine  are — water,  urea, 
uric  acid,  hippuric  acid,  sodium  chloride,  potassium  and 
sodium  sulphates,  conjugate  sulphate  as  indiean,  earthy  and 
alkaline  phosphates,  sometimes  carbonates  and  oxalates,  and 
the  coloring  matter  urochrome,  urobilin  and  uroerythrin. 

Describe  gastric  digestion,  with  special  reference  to  the 
changes  effected  upon  the  types  of  food. 

When  the  food  reaches  the  stomach  the  two  openings  close 
and  the  involuntary  nniscle  contracts  down  on  the  mass  and 
starts  up  a  churning-like  movement,  by  which  fresh  portions 
of  food  are  constantly  brought  to  the  surface.  At  the  end 
of  an  hour  the  pyloric  orifice  gi-adually  relaxes,  allowing  some 
of  the  more  liquid  chyme  to  pass  into  the  duodenum,  and  by 
the  end  of  three  or  four  hours  even  the  larger  pieces  of  un- 
digested food  are  forced  into  the  duodenum.  During  this 
time  the  gastric  juice  is  being  poured  out  from  the  nnicous 
membrane.  The  act  of  mastication  and  deglutition  and  the 
irritation  of  sensory  vagus  endings  in  the  stomach  by  the  food 
act  as  powerful  refiex  excitants  to  this  secretion. 

The  ptyalin  of  the  saliva  continues  to  change  starch  into 
maltose  until  the  increasing  acidity  of  the  gastric  juice  stops 
its  action. 
15 


226  PHYSIOLOGY. 

The  fats  are  liquified,  but  it  is  upon  the  proteids  that  the 
chief  action  takes  place.  The  rennin  changes  caseinogen 
into  casein.  The  pepsin  in  the  presence  of  the  hydrochloric 
acid  changes  the  proteids  into  proteoses  and  peptones. 

Describe  the  process  of  segmentation  of  the  ovum. 

The  impregnated  ovum  first  divides  into  two  cells  by  in- 
direct division  or  karyokinesis,  these  again  subdivide,  con- 
tinuing until  finally  a  single  layer  of  cells  surrounding  a 
central  cavity  is  formed.  One  group  of  cells  proliferates 
more  rapidly  than  the  other  and  as  a  result  they  become  sur- 
rounded by  the  other  layer;  thus  two  leaves  are  formed, 
Between  these  a  third  layer  or  mesoblast  is  formed.  From 
this  blastoderm  the  animal  is  now  developed. 

What  is  the  relation  of  the  capillaries  to  the  circulation? 

The  capillaries  connect  the  small  arterioles  with  the  small- 
est veins.     They  are  situated  at  the  periphery. 

What  precautions  should  be  taken  in  the  ingestion  of 
vegetable  foods?  Give  the  reasons  for  taking  these  pre- 
cautions. 

Vegetable  foods  should  be  well  cooked  so  as  to  burst  the 
cellulose  covering  of  the  starch  granules;  they  should  be 
well  chewed  so  as  to  break  up  the  cellulose  covering.  Some 
fatty  food  should  be  taken  with  them  as  they  are  deficient 
in  fats.  As  some  of  them  contain  but  little  nutritive  ma- 
terial they  should  be  taken  in  large  quantities  for  obvious 
reasons. 

Describe  the  process  of  osmosis  and  give  examples  in 
the  human  economy. 

Osmosis  is  the  diffusion  of  liquids  through  a  porous  mem- 
brane. 

For  osmosis  to  take  place  the  liquids  must  be  miscible,  of 
different  natures,  capable  of  wetting  the  membrane  -without 
acting  on  it  chemically,  and  the  substance  must  be  able  to 
pass  through  the  membrane,  that  is,  be  crystalloidal  in  nature. 
Heat,  increase  of  pressure  and  electricity  aid  osmosis. 


PHYSIOLOGY.  227 

The  following  are  examples  of  osmosis:  (1)  The  passage 
of  some  of  the  plasma  through  the  capillary  wall  into  the 
tissues.  (2)  The  passage  of  glucose  from  the  intestine  into 
the  poral  circulation. 

Name  the  secretions  of  the  alimentary  canal  and  give 
the  functions  of  each. 

Saliva  changes  starch  into  maltose  and  dextrin,  dissolves 
soluble  substances,  thus  allowing  them  to  be  tasted,  lubricates 
the  bolus  of  food  and  aids  in  speech. 

Gastric  juice  changes  caseinogen  into  casein,  and  proteids 
into  proteoses  and  peptones.  It  also  destroys  many  micro- 
organisms swallowed  in  the  food. 

Pancreatic  secretion  changes  proteids  into  proteoses  and 
peptones,  starch  into  maltose,  dextrose,  and  dextrin,  casein- 
ogen into  casein,  and  splits  up,  saponifies  and  emulsifies  fats. 

Bile  neutralizes  the  acid  chyme  precipitating  the  pepsin, 
aids  in  the  emulsifieation  and  absorption  of  fats,  increases 
peristalsis,  and  carries  off  some  of  the  waste  thrown  out  by 
the  liver. 

Succus  entericus  changes  maltose  into  glucose,  and  sac- 
charose into  invert  sugar. 

The  alimentary  canal  has  also  the  usual  protecting  and 
lubricating  secretion  of  mucus. 

Describe  urea,  its  occurrence,  variations  in  the  quantity 
excreted  and  recognition  in  the  voided  urine. 

Urea,  CO  (NIL)  2,  the  great  nitrogenous  waste,  is  a  crystal- 
lizable  substance  soluble  in  water,  less  soluble  in  alcohol,  neu- 
tral in  reaction  and  forming  with  nitric  acid  urea  nitrate. 
About  500  grains  daily  are  thrown  off  in  the  urine  by  the 
kidneys.  It  is  formed  in  the  liver  (|)  and  in  the  intestines 
(^).  It  varies  principally  with  the  amount  of  nitrogenous 
food  in  the  diet.  Muscular  exercise  does  not  increase  it 
to  any  marked  extent.  It  is  recognized  by  adding  nitric  acid 
to  a  concentrated  urine,  when  urea  nitrate  separates  out  in 
a  crystalline  mass,  also  by  the  hypobromite  test. 


228  PHYSIOLOGY. 

What   is   rigor  mortis?     What  is   tetanus? 

Rigor  mortis  is  the  post-mortem  rigidity  of  the  muscles  due 
to  the  coagulation  of  the  myosinogen. 

Tetanus  is  a  state  of  continued  contraction  of  a  living 
muscle. 

Give  the  varied  functions  of  the  sympathetic  nerve. 

The  function  of  the  sympathetic  system  is  mainly  vaso- 
motor. It  also  supplies  the  heart  with  accelerating  fibers, 
the  intestines  with  inhibitory  and  some  motor  fibers;  dilates 
the  pupil,  and  causes  a  bulging  of  the  eyeball.  It  also  has 
an  influence  on  the  salivary  secretion. 

How  are  the  phenomena  of  ventriloquism  produced? 

Instead  of  the  usual  expiratory  blast,  an  inspiratory  blast 
is  used  in  producing  the  vocal  sounds.  At  the  same  time 
the  operator  directs  the  attention  of  the  onlookers  to  some 
object. 

Describe  the  mechanism  of  micturition. 

Usually  it  is  a  mixture  of  a  voluntary  and  involuntary  re- 
flex act.  The  reflex  center  is  situated  in  the  lumbar  cord. 
Stimulation  of  this  center  is  ordinarily  caused  by  a  full 
bladder  or  by  the  escape  of  a  drop  of  urine  into  the  urethra, 
but  may  be  excited  by  irritation  of  sensory  nerves  of  other 
surfaces,  as  the  intestinal  mucous  membrane  by  worms. 
Ordinarily  the  sphincter  of  the  bladder  is  inhibited,  the 
muscular  wall  contracts,  and  aided  by  the  abdominal  and 
other  expiratory  muscles  forces  the  urine  out  through  the 
urethra.  There  are  higher  centers  that  have  control  over 
the  lower  reflex  centers. 

Name  the  ferments  that  are  the  essential  constituents 
of  each  digestive  fluid. 

Ptyalin  is  found  in  saliva ;  pepsin  and  rennin  in  gastric 
juice:  amylopsin,  steapsin,  trypsin  and  a  milk-curdling  fer- 
ment in  the  pancreatic  juice ;  invertin  in  the  succus  entericus ; 
and  the  micro-organisms  or  organized  ferments  in  the  intes- 
tines.   Bile  contains  no  ferment. 


PHYSIOLOGY.  229 

What  are  the  functions  of  the  spinal  cord? 

The  spinal  cord  is  the  great  motor  and  sensory  pathway 
to  and  from  the  periphery.  In  the  anterior  horns  are  found 
the  cells  concerned  in  the  muscular  reflexes,  and  also  the 
trophic  centers  for  the  muscles.  Besides  the  muscular  reflex- 
centers,  the  cord  contains  the  following  centers :  Anospinal, 
vesicospinal,  geuitospinal,  uterospinal,  sweat,  minor  vaso- 
motor and  possibly  ciliospinal. 

What  post=mortem  tests  should  be  applied  to  prove  that 
air  has  entered  the  lungs  of  a  supposedly  stiiUborn  child? 

Tie  the  trachea,  take  out  the  liuigs  and  place  them  in 
water.  If  they  float,  air  has  entered  the  lungs.  The  thorax 
is  not  as  flat  after  respiration  has  started  and  the  diaphragm 
is  displaced  further  downward.  The  lungs  are  'brighter  in 
color  and  are  crepitant  after  air  lias  once  entered. 

Wherein  does  the  temperature  of  the  body  in  advanced 
age  differ  from  its  temperature  in  middle  life? 

In  advanced  age  the  temperature  ha.s  a  tendency  to  be- 
come subnormal  fi-om  the  slightest  cause. 

Give  in  language  or  by  drawing  the  sphygmographic 
tracing  in  aortic  insufficiency. 

In  aortic  insufficiency  there  is  the  so-calletl  "  trip  hammer 
pulse."  In  the  sphygmogram  there  is  a  very  high,  quick  up- 
stroke and  an  almost  as  quick  downstroke  due  to  the  rapid 
decrease  in  i)ressure  caused  by  the  regurgitation.  On  the 
downstroke  a  small  dicrotic  wave  is  seen. 

What  are  amyloid  foods,  proteid  foods?  Give  three  ex- 
amples of  each. 

The  amyloid  foods  are  the  carbohydrates  in  the  molecule 
of  which  are  six  or  nuiltiple  of  six  atoms  of  carbon,  and 
hydrogen  and  oxygen  in  the  proiK)rtion  to  foi-m  water. 
Starch,  cane  sugar  and  glycogen  and  amyloids. 

Proteids  are  highly  complex  bodies  containing  carbon,  hy- 
drogen, oxygen,  nitrogen,  sulphur  and  sometimes  phosphorus. 
Egg  albumen,  casein  and  gluten  are  proteids. 


230  PHYSIOLOGY. 

How  is  cartilage  (a)  developed,  (b)  nourished? 

Cartilage  is  developed  from  the  mesoblast.  The  cells  are 
not  branched.  By  karyoldnetie  changes  they  divide  and 
subdivide.  Each  cell  is  surrounded  by  a  capsule  which  helps 
to  form  a  portion  of  the  matrix.  But  beside  this,  other  ma- 
terial is  deposited  in  the  intercellular  spaces. 

Cartilage  is  nourished  by  the  perichondrium  except  arti- 
cular cartilage,  which  is  nourished  from  the  underlying  bone. 

Describe  nerve  cells  and  nerve  fibers. 

The  nerve  cells  are  nucleated  masses  of  granular  proto- 
plasm with  one  or  more  protoplasmic  prolongations  called 
dcndrons.  Passing  off  from  most  nerve  cells  is  a  long  fiber 
or  axis  cylinder. 

The  nerve  fibers  are  either  meduUated  or  non-medullated. 
The  medullated  fibers  consist  of  an  axis  cylinder  or  neur- 
axon,  surrounded  by  the  myelin  or  white  substance  of 
Schwann,  which  in  turn  is  covered  with  the  neurilemma  or 
sheath  of  Schwann.  An  internal  layer  of  protoplasm  separ- 
ates the  myelin  from  the  neuraxon,  and  an  external  layer 
separates  the  myelin  from  the  neurilemma.  Here  and  there 
along  the  course  of  the  nerve  are  found  the  nodes  of  Ranvier. 
The  non-medullated  fibers  contain  no  myelin. 

What  experiments  have  been  made  to  prove  the  glyco- 
genic function  of  the  liver? 

The  blood  of  the  portal  vein  during  active  digestion  of  a 
carbohydrate  meal  contains  more  sugar  than  the  hepatic 
vein,  showing  the  arrest  of  dextrose  in  the  liver.  The  hepatic 
vein  in  the  intervals  of  digestion  contains  twice  as  much 
dextrose  as  that  in  the  blood  entering  the  liver. 

If  a  rabbit  that  has  been  fed  on  carrots  is  killed  and  the 
liver  rapidly  removed,  cut  into  small  pieces  and  thrown  into 
boiling  water,  it  yields  an  extract  rich  in  glycogen  and  al- 
most free  of  dextrose. 

If  another  animal  is  treated  the  same  but  the  liver  al- 
lowed to  stand  for  some  time  before  making  an  extract,  the 
extract  will  contain  much  dextrose  and  but  little  glycogen. 


PHYSIOLOGY.  231 

The  carbohydrate  of  blood  is  dextrose  and  not  glycogen. 
Under  the  microscope,  glycogen  granules  are  found  in  the 
protoplasm  of  the  liver  cells. 

Give  the  function  of  the  epiglottis. 

The  epiblottis  is  used  in  vocalization,  especially  of  the  lower- 
pitched  tones. 

What  differences  of  function  exist  between  the  white 
and  gray  matter  of  the  encephalon? 

The  gray  matter  is  composed  of  cells,  which  are  the  ter- 
minals that  receive  sensations,  classify  the  knowledge  thus 
received,  and  send  out  impulses. 

The  white  matter  is  made  up  of  fibers  that  transmit  the 
impulses,  connecting  the  cells  with  each  other  and  with  the 
periphery. 

Describe  the  ileocecal  function. 

The  ileocecal  valve  is  composed  of  two  semilunar  folds 
of  mucous  membrane,  containing  the  circular  fibers.  When 
the  cecum  is  distended  this  valve  is  closed,  and  thus  re- 
gurgitation into  the  small  intestine  is  prevented. 

State  the  approximate  time  of  eruption  of  the  tempo- 
rary teeth. 

The  lower  central  incisors  erupt  about  the  5th  or  6th 
month,  followed  rapidly  by  the  other  six  incisors.  About 
the  11th  or  12th  month  the  first  molars  appear.  From  the 
18th  to  20th  month  the  canines  erupt,  followed  from  the  24th 
to  30th  month  by  the  second  molars. 

State  what  are,  under  normal  conditions,  the  (a)  adult 
number  of  respirations  per  minute;  (b)  body  tempera- 
ture; (c)   average  respiratory   capacity. 

Respiratory  rate  is  eighteen  per  minute;  the  body  tem- 
perature is  98.4°  Fahr. ;  the  average  respiratory  capacity  is 
230  cubic  inches. 

Name  two  circumstances  influencing  secretion. 

Among  circumstances  influencing  secretion  are  the  supply 


232  PHYSIOLOGY. 

of  blood  to  the  gland  and  the  proper  action  of  the  normal 
reflex  excitants. 

What  is  the  function  of  (a)  sudoriferous  glands;  (b) 
the  sebaceous  glands? 

The  function  of  the  sudoriferous  glands  is  to  excrete 
sweat;  that  of  the  sebaceous  glands  to  secrete  sebum. 

Name  the  principal  centers  of  organic  function  in  the 
medulla  oblongata. 

The  principal  centers  in  the  medulla  are  the  respiratory, 
cardio-inhibitory,  cardio-accelerator,  vasomotor,  salivation, 
mastication,  deglutition,  vomiting  and  diabetic. 

Account  for  the  contraction  and  dilatation  of  the  pupil. 

The  contraction  and  dilatation  of  the  pupil  is  a  reflex 
phenomenon  regulating  the  amount  of  light  and  sharpening 
the  image  for  near  objects. 

There  are  two  sets  of  muscular  fibers  in  the  iris — circular  or 
contracting  and  radiating  or  dilating. 

Give  the  composition  of  normal  feces. 

The  feces  contain  70  to  80%  of  water.  Of  the  solid  mat- 
ter there  are  indigestible  substances  as  cellulose,  mucin  and 
keratin ;  some  undigested  matter  as  uncooked  starch  and 
elastin ;  products  of  microbic  digestion  as  indol,  skatol, 
phenol,  fatty  acids  and  leucin;  bacteria;  cholesterin;  color- 
ing matters,  stercobilin ;  and  intestinal  debris  as  cells  and 
mucus.  They  are  alkaline  in  reaction,  quantity,  6  to  8  ounces 
in  24  hours. 

Describe  the  disturbances  of  function  produced  by  the 
excessive   imbibition  of  alcohol. 

Excessive  imbibition  of  alcohol  causes  congestion  of  the 
stomach  with  altered  gastric  secretion,  precipitation  of  pepsin 
during  gastric  digestion,  congestion  of  liver  and  finally  de- 
struction of  many  of  the  liver  cells.  On  entering  the  cir- 
culation it  acts  as  an  irritant  to  the  whole  vascular  system 
and  to  the  kidneys.    It  also  causes  subnormal  temperature. 


PHYSIOLOGY.  233 

How  are  cells  connected? 

Cells  are  connected  by  the  intercellular  substances. 

What  changes  take  place  in  the  composition  of  blood  as 
it  passes  through  the  kidneys? 

During  the  passage  of  the  blood  through  the  kidneys,  these 
organs  pick  out  of  it  large  quantities  of  urea,  uric  acid, 
sodium  chloride,  alkaline  and  earthy  phosphates,  sodium  and 
potassium  sulphates,  indican,  extractives  and  water.  The 
blood  also  becomes  venous,  losing  oxygen  and  adding  more 
carbon  dioxide. 

How  are  the  vocal  sounds  produced? 

The  vocal  sounds  are  produced  by  vibrations  of  the  vocal 
cords,  modified  in  the  case  of  vowels  by  peculiarities  in  the 
shape  of  the  resonating  cavities  above,  mouth,  pharynx  and 
nasal  cavities.  In  the  case  of  consonants  the  vibrations  are 
modified  by  a  more  or  less  complete  interference  with  the 
outgoing  flow  of  air. 

What  would  be  the  effect  on  the  saliva  and  on  digestion 
if  Stenson's  duct  should  be  divided? 

If  Stenson's  duct  should  be  divided,  the  other  parotid 
would  probably  hypertrophy  somewhat  to  make  up  for  the 
loss  of  secretion.  There  would  be  comparatively  little  effect 
on  the  saliva  or  digestion.  At  first  mixed  saliva  would  pos- 
sibly be  less  watery  and  the  digestion  of  starch  somewhat 
retarded. 

Describe  the  physiologic  aspect  of  atavism. 

Atavism  is  the  peculiarity  of  the  offspring  of  taking  on 
the  characteristics  of  the  parent. 

Certain  characteristics,  inherent  in  the  ovum  and  spermato- 
zoon and  derived  from  the  parents,  cause  special  develop- 
ment in  certain  lines,  thus  causing  the  offspring  to  take  on 
peculiarities  of  the  parents. 

Give  the  extremes  of  slowness  and  rapidity  of  the  heart's 


234  PHYSIOLOGY. 

action  which  are  consistent  with  physical  vigor,  and  with 
ability  to  perform  manual  labor. 

The  extremes  would  probably  be  from  fifty  to  a  hundred 
beats  per  minute;  nevertheless,  no  definite  extremes  can  be 
given. 

Give  the  process  of  regeneration  of  uterine  mucous 
membrane  following  pregnancy. 

Following  pregnancy  the  mucous  membrane  of  the  uterus 
is  regenerated  from  the  epithelium  of  the  deep  glandular 
layer.  Around  the  mouth  of  the  glands  proliferation  goes  on 
rapidly,  the  groups  of  new  cells  spreading  out  and  finally 
coalescing  with  each  other.  About  the  end  of  the  fifth  week 
this  new  membrane  is  complete.  All  cells  and  shreds  of 
decidual  tissue  not  concerned  undergo  fatty  degeneration  and 
are  thrown  off  in  the  lochial  discharge. 

In  what  manner,  physiologically,  does  a  largely  dis= 
tended  stomach  produce  death? 

A  largely  distended  stomach  may  eause  death  by  interfer- 
ence with  normal  digestion,  causing  excessive  fermentation 
and  auto-intoxication.  Or,  pressure  on  the  surrounding  or- 
gans causes  interference  with  the  circulation  and  the  func- 
tions of  these  organs.  The  venous  stasis  causes  hypertrophy 
and  dilatation  of  the  heart,  which  finally  gives  out,  death 
ensuing. 

Give  the  physiological  properties  of  the  facial  nerve. 

The  facial  nerve  is  the  motor  nerve  for  the  muscles  of 
expression  of  the  face. 

Describe  hemoglobin  and  mention  its  derivatives. 

Hemoglobin  is  a  proteid-like  body,  readily  crystallizable  and 
containing  iron.  It  readily  unites  with  oxygen  and  other 
gases  and  has  a  characteristic  spectrum.  On  the  addition  of 
an  acid  or  alkali,  it  is  broken  up  into  hematin  and  globin,  the 
latter  a  proteid  of  the  globulin  group. 

Hematin,  hematoidin,  hemin,  hematoporphyrin  and  methe- 
moglobin  are  derivatives  of  hemoglobin. 


PHYSIOLOGY.  235 

Define  and  give  the  physiologic  significance  of  (a)  dys= 
pnoea,  (b)  dysphagia,  (c)  apnoea. 

Dyspnoea,  or  difficult  breathing,  is  caused  by  a  deficient 
supply  of  oxygen  to  the  tissues. 

Dysphagia,  or  difficult  or  painful  deglutition,  may  be 
caused  by  obstruction  in  the  esophagus,  reflex  spasm,  or  by 
painful  affections  of  the  pharynx. 

Apnoea,  or  cessation  of  breathing,  is  caused  by  the  blood 
being  overcharged  with  oxygen,  or  by  a  reflex  inhibition  of 
the  respiratory  center. 

What  prevents  digestion  of  the  stomach  by  its  own 
juices? 

The  reason  that  the  stomach  is  not  digested  by  its  own 
juices  is  not  known,  so  it  is  said  to  be  due  to  a  vital  act. 
Neither  the  alkalinity  of  the  mucous  membrane,  nor  the  alka- 
linity of  the  blood  will  explain  it. 

Give  the  physiology  of  (a)  blushing,  (b)  pallor,  (c)  tear 
shedding. 

Blushing  is  a  reflex  dilatation  of  the  bloodvessels  of  the 
skin.  Some  emotional  disturbance  so  stimulates  the  vasodi- 
lator center  in  the  medulla  as  to  cause  a  vasodilatation  of  the 
skin  vessels. 

Pallor  is  a  reflex  vasoconstriction  of  the  bloodvessels  of 
the  skin.  It  is  caused  by  a  reflex  excitation  of  the  vasocon- 
strictor center  in  the  medulla. 

Certain  emotions  so  reflexly  stimulate  the  lachrymal  glands 
through  the  central  nervous  system  as  to  cause  the  glands 
to  secrete  more  fluid  than  can  be  carried  off  through  thp 
nasal  duct.  The  excess  runs  over  the  cheeks  and  is  called 
tears. 

What  causes  (a)  circulation  of  the  blood,  (b)  the  beat- 
ing of  the  pulse? 

The  circulation  of  the  blood  is  caused  by  the  action  of  the 
heart,  aided  by  the  vasomotor  system. 

The  beating  of  the  pulse  is  caused  l)y  the  transmission  of 
the  cardiac  impulse  through  the  elastic  arterial  system. 


236  PHYSIOLOGY. 

What  are  the  functions  of  the  pancreas? 

The  pancreas  secretes  the  pancreatic  juice.  In  addition 
to  this,  it  has  an  internal  secretion,  because  extirpation  of 
the  pancreas  causes  diabetes. 

What  substances  are  absorbed  principally  in  (a)  the 
stomach,  (b)  the  duodenum? 

Alcohol,  water  and  soluble  salts  are  absorbed  in  large 
quantities  by  the  stomach.  The  fats,  proteids  and  glucose 
are  absorbed  in  the  duodenum  and  in  the  rest  of  the  small 
intestines. 

Describe  the  conditions  within  normal  physiological 
limits  which  increase  arterial  blood  pressure. 

Anything  that  will  directly  or  indirectly  cause  stimulation 
of  the  vasomotor  center  will  cause  an  increase  in  arterial 
pressure. 

Among  these  causes  we  have  digestion,  muscular  exercise, 
various  emotions,  as  fear  and  joy,  increased  resistance  in  the 
capillary  system,  dyspnoea  and  asphyxia. 

Name  the  inorganic  proximate  principles  that  enter  into 
the  formation  of  the  human  body. 

The  inorganic  proximate  principles  entering  into  the  for- 
mation of  the  human  body  are  water  and  the  various  salts, 
as  sodium  chloride,  potasium  sulphate,  calcium  fluoride  and 
magnesium  phosphate. 

What  do  you  understand  by  the  term  nutrition,  and 
what  processes  are  comprised  under  it? 

By  nutrition  is  meant  the  taking-in  of  nutrient  material, 
its  conversion  into  living  protoplasm,  and  the  throwing-off 
of  waste  matter  from  the  cell. 

It  includes  digestion,  absorption,  metabolism  and  excretion. 

What  are  the  Wolffian  bodies?  When  do  they  appear 
and  into  what  organs  do  they  ultimately  develop? 

The  Wolffian  bodies  are  the  temporary  kidneys  of  early 
intra-uterine  life,   appearing  about  the  third  w^eek.     In  the 


PHYSIOLOGY.  237 

female  they  become  the  parovarium;  and  in  the  male,  form 
the  globus  major,  vas  efferent ia  and  coni  vasculosi. 

What  is  the  composition  of  human  milk? 

Milk  contains  112  parts  of  solid  matter  to  the  thousand. 
Of  these,  sixty  parts  are  the  carbohydrate,  lactose;  thirty 
are  fats,  olein,  palmitin,  stearin  and  butyrin;  twenty  are 
proteids,  caseinogen,  lactalbumin  and  lacglobulin ;  and  two 
parts  are  salts,  especially  sodium  chloride  and  calcium  phos- 
phate. 

>Vhat  are  the  uses  of  perspiration? 

Through  the  perspiration  we  get  rid  of  certain  waste  pro- 
ducts, supplementing  somewhat  the  action  of  the  kidneys. 
Through  it  we  also  throw  off  large  quantities  of  heat.  It  also 
keeps  the  skin  moist. 

What  conditions  increase  the  amount  of  solids  in  the 
urine? 

Increased  ingestion  of  salts  will  increase  the  amount  of 
salts  excreted. 

Diarrhoea,  free  perspiration  and  limiting  the  ingestion  of 
fluids,  will  cause  a  relative  increase  of  solids.  Excessive 
muscular  exercise  will  also  cause  a  small  increase  in  the 
amount  of  solids. 

What  are  the  functions  of  the  pneumogastric  nerve? 

Among  its  many  functions  the  pneumogastric  is  motor  and 
sensory  to  the  larynx,  motor  to  the  pharnx  and  oesophagus, 
motor,  sensory  and  secretory  to  the  stomach,  inhibitory  of  the 
heart,  motor  and  sensory  to  the  lungs,  and  sends  more  fila- 
ments through  the  sympathetic  system  to  the  pancreas,  liver 
and  intestines. 

How  are  the  sensations  of  color  produced? 

According  to  the  Yung-llelmholtz  theory  there  are  tliree 
sets  of  retinal  fibers,  each  responding  to  the  stimulation  of 
one  of  the  primary  colors,  green,  red  and  violet.  Stimula- 
tion of  these  in  ditferent  degrees  causes  the  various  shades. 


238  PHYSIOLOGY. 

According  to  the  Hering  theory  there  is  one  set  of  fibers, 
while  there  are  three  chemical  substances  found  in  visual 
purple.  The  anabolism  of  these  causes  white,  red  and  yellow, 
katabolism,  black,  green  and  blue.  Various  combinations 
cause  various  shades. 

Describe  the  portal  circulation;  the  renal  circulation. 

The  blood  collected  from  the  capillaries  of  the  spleen, 
stomach  and  intestines  by  the  splenic,  gastric,  inferior  and 
superior  mesentric  veins  is  carried  by  the  portal  vein  to 
the  liver.  Here  this  vein  breaks  up  into  smaller  vessels 
running  between  the  lobules,  called  the  interlobular  vessels. 
These  break  into  a  set  of  capillaries,  called  the  lobular  capil- 
laries, which  coalesce  to  form  the  intralobular  veins.  These 
empty  into  the  sublobular  veins,  which  in  turn  form  the 
hepatic  vein  which  carries  the  blood  into  the  inferior  vena 
cava.  The  hepatic  artery  supplies  especially  the  capsule  of 
the  liver. 

In  the  kidneys  we  find  three  sets  of  capillaries.  One  set 
is  that  of  the  vasa  recta,  short  vessels  given  off  from  the 
arterial  trunks  and  supplying  the  medullary  portion.  Then 
we  have  the  arteries  of  the  cortex  forming  the  set  of  capil- 
laries of  the  glomeruli.  The  vessels  passing  out  from  the 
glomeruli  are  called  the  efferent  vessels,  and  again  break 
up  into  a  set  of  capillaries  around  the  convoluted  portion  of 
the  tubules.  The  blood  is  then  collected  by  the  renal  venules 
and  passes  out  through  the  renal  vein. 

What  circumstances  and  conditions  favor  gastric  diges- 
tion? 

Among  the  many  circumstances  favoring  gastric  digestion 
are  thorough  mastication,  sIoav  eating,  pleasant  taste  to  the 
food,  swallowing  in  small  mouthfuls,  normal  amount  of  con- 
diments, muscular  and  mental  quietude,  and  a  general  healthy 
condition  of  the  various  parts  of  the  body. 

Describe  the  physiology  of  vomiting. 

Vomiting  is  the  spasmodic  rejection  of  the  contents  of  the 


PHYSIOLOGY.  23i> 

stomach.  It  may  occur  from  an  abnormal  condition  of  the 
vomiting  center  of  the  medulla,  or  reflexly  from  the  irrita- 
tion of  many  nerves,  as  the  glossopharyngeal  in  the  posterior 
surface  of  the  larynx,  or  the  pneumogastric  in  the  stomach, 
or  from  the  sight  of  disgusting  objects,  disgusting  tastes  or 
smells,  or  from  irritation  of  other  mucous  membranes,  as  the 
uterus. 

During  the  act  of  vomiting  the  diaphragm  is  fixed,  the 
cardiac  orifice  of  the  stomach  is  opened  by  the  longitudinal 
fibers  and  the  abdominal  muscles  contract,  causing  the  con- 
tents of  the  stomach  to  be  forced  into  the  mouth. 

What  would  be  the  effect  on  digestion  if  the  pancreatic 
duct  were  obstructed? 

As  the  pancreatic  secretion  acts  on  all  classes  of  food,  there 
would  be  a  marked  decrease  in  the  whole  digestive  function, 
especially  on  the  fats  and  proteids. 

Discuss  bacteria  in  the  intestines. 

The  bacteria  found  in  the  intestines  may  be  divided  into 
three  groups — fermentative,  chromogenie  and  pathogenic. 

The  first  class  is  very  useful,  forming  peptones,  dextrose 
and  fatty  acids,  and  breaking  up  some  poisonous  principles, 
as  choline,  into  simpler  bodies.  Unless  putrefaction  becomes 
excessive,  it  is  perfectly  normal. 

Among  other  substances  formed  during  microbic  digestion 
are  indol,  skatol,  phenol,  carbon  dioxide,  leucin,  tyrosin,  hy- 
drogen sulphide  and  ammonia. 

Give  the  relative  activity  of  absorption  in  the  alimen- 
tary canal,  the  skin  and  the  lungs. 

The  relative  activity  of  absorption  is  first  through  the 
lungs,  then  through  the  alimentary  canal,  and  third  through 
the  skin. 

Give  the  process  of  replacement  of  temporary  by  per- 
manent teeth. 

As  the  jaws  grow  and  can  accommodate  the  larger  per- 
manent teeth,   tlie  little   iiimiature  permanent  teeth  budded 


240  PHYSIOLOGY. 

oft'  from  the  temporary  set  begin  to  grow  upward.  As  they 
grow,  the  fangs  of  the  temporary  teeth  are  gradually  ab- 
sorbed, the  crown  falls  off,  and  then  the  permanent  erupt. 

What  conditions  retard,  suspend  or  prevent  the  coagu= 
lation  of  blood? 

The  conditions  retarding,  suspending  or  preventing  coagu- 
lation are — addition  of  oxalates,  proteoses,  peptones  or  leech 
extract ;  low  teraperatui'e ;  contact  with  living  vascular  walls ; 
the  covering  of  the  surface  with  oil;  addition  of  large  quan- 
tities of  neutral  salts ;  excess  of  carbon  dioxide ;  death  by 
lightning;  and  the  diseased  condition,  hemophilia. 

What  is  the  function  of  the  superior  laryngeal  nerves? 

The  superior  laryngeal  nerves  are  the  motor  for  the  crico- 
thyroid muscles  and  the  sensory  for  the  larynx. 

Discuss  the  effect  of  the  cooking  of  food  as  a  means  of 
rendering  it  more  digestible. 

It  is  especially  on  the  starchy  foods  that  cooking  has  a 
good  effect  by  breaking  up  the  cellulose  covering  of  the  starch 
granules  and  changing  some  of  the  starch  into  dextrin. 

The  fats  in  the  cells  are  also  liberated. 

Upon  the  proteids  cooking  has  rather  a  detrimental  eft'ect, 
especially  if  the  temperature  is  raised  very  high.  For  in- 
stance, the  uncooked  egg  albumin  is  more  readily  digested 
than  the  coagulated  cooked  albumin. 

What  agencies  induce  the  flow  of  lymph  to  the  point 
of  discharge  in  the  veins? 

The  flow  of  lymph  is  induced  by  the  vis  a  tergo  or  pressure 
in  the  tissues,  by  muscular  action  and  the  play  of  the  numer- 
ous lymphatic  valves,  by  muscular  tissue  in  the  lymphatic 
vessels,  and  by  thoracic  suction. 

Name  some  of  the  involuntary  muscles  and  the  function 
with  which  each  is  concerned. 

The  uterus  is  the  organ  for  the  carrying  of  the  developing 
embryo  and  foetus.  The  muscle  is  used  for  the  expulsion  of 
the  foetus  at  the  end  of  intra-uterine  life. 


PHYSIOLOGY.  241 

The  muscular  wall  of  the  intestine  is  used  for  mixing  and 
passing  on  downward  the  food  received  from  the  stomach. 

The  tunica  media  of  the  arteries  contains  many  muscular 
fibers  that  control  the  supply  of  blood  by  modifying  the  size 
of  the  vessel. 

What  do  you  understand  by  blood  pressure? 

Blood  pressure  is  the  pressure  to  which  the  blood  is  sub- 
jected in  the  circulatory  system.  In  man  it  is  about  110 
millimeter  of  mercury. 

What  effect  does  an  excessive  starchy  diet  produce? 

It  produces  excessive  flatulency  and  may  lead  to  an  ali- 
mentary glycosuria. 

Give  the  mechanism  of  the  organs  of  hearing. 

The  sound  waves  are  converged  by  the  auricle,  pass  through 
the  external  auditory  meatus,  striking  then  against  the  mem- 
brana  tympani,  which  sets  into  movement  the  ossicles,  malleus, 
incus  and  stapes.  The  base  of  the  stapes  fits  into  the  oval 
window.  Thus  the  sound  waves  cause  a  movement  of  the 
ossicles,  which  in  turn,  through  the  base  of  the  stapes,  cause 
vibrations  to  be  set  up  in  the  perilymph  of  the  vestibule ;  then 
they  are  conveyed  through  the  scala  vestibuli  and  through 
the  helicotrenia  to  the  perilymph  of  the  scala  tympani,  and 
out  through  the  round  window  to  be  dispersed. 

The  vibration  of  the  perilymph  in  the  cochlea  sets  up 
vibration  in  the  scala  media  containing  the  organs  of  Corti, 
which  are  the  essential  receptive  organs  of  hearing. 

The  impressions  received  are  carried  by  the  cochlear  branch 
of  the  auditory  nerve  to  the  cerebrum. 

What  is  meant  by  digestion? 

The  nutrient  material  or  food  ingested  has  to  be  so  changed 
that  it  can  be  absorbed.     This  changing  of  the  food  is  called 
digestion. 
16 


242  PHYSIOLOGY. 

What  influence  has  the  nervous  system  on  the  process 
of  secretion? 

The  nervous  system  controls  the  process  of  secretion  by 
the  various  secretory  centers  and  nerves,  and  by  controlling 
the  amount  of  blood  to  the  various  organs  of  the  body. 

Name  the  refracting  media  of  the  eye  and  the  effect  that 
each  has  on  the  rays  of  light. 

The  refracting  media  of  the  eye  are  the  cornea,  aqueous 
humor,  crystalline  lens,  and  the  vitreous  humor. 

They  all  converge  the  rays  of  light,  the  cornea  being  the 
most  potent,  the  crystalline  lens  coming  next,  then  the  vitreous 
and  finally  the  aqueous  humor. 

What  is  the  location  of  the  center  for  articulate  speech? 

The  center  for  articulate  speech  is  in  Broca's  convolution, 
the  left  lower  frontal  in  right-handed  people. 

How  is  the  sensation  of  pain  produced? 

Stimulation  of  the  special  endings  of  the  pain  nerves  in 
the  skin,  or  stimulation  of  the  trunk  of  the  nerve,  causes  an 
impression  to  be  sent  to  the  special  area  of  the  brain  pre- 
siding over  pain  sensations.  When  this  center  is  so  stimu- 
lated we  feel  pain. 

What  kinds  of  food  would  you  recommend  in  cases  of 
obesity? 

The  whole  diet  including  water  should  be  restricted  and 
the  relative  amount  of  proteids  greatly  increased  in  eases  of 
obesity. 

Give  the  reactions  of  the  following  fluids  and  state  the 
cause  of  the  reaction  in  each  case:  blood,  gastric  juice 
and  pancreatic  juice. 

Blood  is  alkaline  from  its  contained  alkaline  phosphates 
and  carbonates. 

Gastric  juice  is  acid  from  the  hydrochloric  acid  in  it. 

Pancreatic  juice  is  alkaline  from  the  sodium  carbonate  it 
contains. 


PHYSIOLOGY.  243 

Do  variations  in  the  rate  and  force  of  respiration  affect 
the  heart,  and  if  so,  in  what  manner? 

Increase  in  the  rate  and  force  of  respiration  increases  the 
number  and  force  of  the  heart-beats.  A  deep  inspiration 
held  for  some  time  Avill  reduce  the  rate  of  a  rapid  heart. 

Name  the  organs  of  the  special  senses. 

The  organs  of  special  sense  are  the  eye,  ear,  upper  por- 
tion of  the  nasal  cavity,  the  taste  bulbs  on  the  tongue,  and  the 
tactile  end  organs. 

Describe  the  functions  of  spinal  nerves. 

The  spinal  nerves  carry  the  afferent  and  efferent  impulses 
of  the  body  and  of  the  back  of  head  to  and  from  the  central 
nervous  system. 

Among  the  afferent  impulses  we  have  those  of  pain,  tem- 
perature, tactile,  pressure  and  muscular  sense. 

Among  the  efferent,  we  have  the  motor,  trophic,  secretory 
and  vasomotor. 

Describe  the  effect  of  a  transverse  section  of  the  spinal 
cord  in  the  mid^dorsal  region. 

A  transverse  dorsal  section  would  cause  paralysis  of  mo- 
tion and  of  sensation  of  the  parts  below  the  section,  paralysis 
of  bladder  and  rectum,  and  exaggerated  reflexes  of  the  legs. 

What  is  meant  by  the  condition  of  tetanus  in  a  muscle? 

When  a  muscle  goes  into  a  state  of  continued  contraction, 
it  is  said  to  be  tetanized. 

Describe  the  digestion  in  the  stomach  of  a  meal  of  bread 
and  milk. 

The  ptyalin  of  saliva  continues  for  some  time  in  the  stomach 
to  change  the  starch  of  the  bread  into  maltose.  The  hydro- 
chloric acid  also  has  some  action  on  the  starch.  The  gluten 
of  the  bread  is  changed  by  pepsin  into  gluten  peptone.  The 
caseinogen  is  changed  into  casein  by  the  rennin,  and  then 
the  pepsin  changes  it  into  proteose  and  peptone. 

The  lactalbumin  and  globulin  are  also  changed  into  pro- 


244  PHYSIOLOGY. 

teoses  and  peptones.    The  soluble  salts  are  dissolved  and  the 
fats  melted. 

What  variations  of  temperature  are  found  in  the  differ= 
ent  parts  of  the  body?  Mention  the  reasons  for  such 
variations. 

The  highest  temperature  is  found  in  the  blood  leaving  the 
liver,  and  is  due  to  the  amount  of  heat  formed  in  this  large 
gland. 

The  tip  of  the  nose  is  said  to  be  the  coldest  part  of  the 
body,  due  to  its  exposed  position  and  to  the  thinness  of  its 
walls. 

The  skin  surface  is  always  cooler  than  the  internal  or- 
gans, due  to  the  radiation  of  the  heat  of  the  blood  from  the 
skin,  the  evaporation  of  sweat  from  the  skin  and  the  in- 
creased amount  of  heat  produced  in  the  internal  organs. 

Describe  the  mechanism  in  the  opening  and  closing  of 
the  aortic  valve. 

The  three  leaflets  of  the  aortic  valve  are  placed  with  their 
concavity  toward  the  aorta.  During  systole  the  pressure  in 
the  ventricles  forces  the  blood  past  the  aortic  valve  into  the 
aorta.  As  the  ventricle  begins  to  dilate  in  diastole  the  pres- 
sure of  the  blood  in  the  aorta  tends  to  force  the  blood  back 
into  the  ventricle.  This  force  fills  up  the  pockets  of  the 
aortic  leaflets  and  forces  their  free  edges  together,  thus  clos- 
ing the  orifice. 

Define  life  and  death. 

"  Life  is  that  obscure  principle  whereby  organized  beings 
are  peculiarly  endowed  with  certain  powers  and  functions 
not  associated  with  inorganic  matter." 

"  Death  is  the  cessation  of  life."     (Dorland.) 

Describe  the  physiology  of  rectal  feeding. 

Small  quantities  of  food,  especially  if  predigested,  when 
placed  in  the  rectum  are  readily  absorbed  and  will  sustain 
life  as  long  as  the  rectum  does  not  become  so  irritable  as  not 


PHYSIOLOGY.  245 

to  retain  the  food.     The  food  should  preferably   be   predi- 
gested,  but  even  egg  albumin  can  be  absorbed. 

What  tests  should  be  applied  to  ascertain  the  integrity 
of  (a>  the  superficial  reflexes,  (b)  the  deep  reflexes? 

To  ascertain  the  integrity  of  superficial  reflexes  we  have 
the  plantar  reflex  or  movement  of  the  toes  on  stroking  the 
sole  of  the  foot;  the  cremasteric,  the  retraction  of  testicle  on 
gently  stroking  the  inside  of  the  thigh;  the  epigastric,  con- 
traction of  abdominal  muscles  on  stroking  the  side  of  the 
abdomen ;  the  ciliospinal,  dilatation  of  the  pupil  on  pinching 
the  skin;  and  many  others. 

Of  the  deep  reflexes,  the  knee  jerk  is  the  one  usually  sought 
after.  On  tapping  the  tendon  below  the  patella  the  quadri- 
ceps is  thrown  into  action.  We  also  have  a  bicipital  reflex 
or  contraction  of  biceps  on  tapping  the  tendon  at  the  elbow. 

What  would  be  the  effect  of  a  transverse  section  of 
(a)  the  anterior  root  of  a  spinal  nerve,  (b)  the  posterior 
root  of  a  spinal  nerve? 

Transverse  section  of  the  anterior  root  would  cause  motor 
paralysis  of  the  muscles  it  supplied,  and  finally  atrophy  of 
the  muscles. 

Transverse  section  of  the  posterior  root  would  cause  loss 
of  sensation  of  the  part  it  supplied. 

Describe  the  physical  properties  of  (a)  lymph,  (b)  chyle. 

Lymph  is  a  yellowish,  salty,  albuminous  liquid,  with  a  spe- 
cific gravity  of  1015.  On  exposure  to  air  it  clots  and  coagu- 
lates on  heating. 

Chyle  is  simply  lymph  plus  the  minute  globules  of  absorbed 
fat,  and  is  milky  white  in  color. 

How  does  impairment  of  the  function  of  one  of  the  fol- 
lowing affect  the  other  two:  (a)  the  skin,  (b)  the  lungs, 
(c)  the  kidneys. 

Impairment  of  the  function  of  the  kidney  causes  increased 
activity  of  the  skin ;  and  at  times  dyspnoea,  asthmatic  at- 


246  PHYSIOLOGY. 

tacks,  urinous  breath,  Cheyne-Stokes  breathing,  and  conges- 
tion of  lungs. 

Describe  an  epithelial  secreting  surface. 

The  mucous  membrane  of  the  stomach  consists  of  a  layer 
of  columnar  epithelium  resting  on  a  layer  of  loose  connective 
tissue,  containing  some  involuntary  muscular  fibers  and  many 
small  blood  vessels  and  lymphatics.  Dipping  down  from 
the  epithelial  layer  are  numerous  small  glands.  These  glands 
are  lined  with  cubical  epithelium  and  secrete  the  gastric  juice. 

In  the  glands  of  the  cardiac  end  and  of  the  fundus,  beside 
the  cubical  cells,  we  also  find  along  the  sides  a  number  of 
spheroidal  cells.  These  are  the  cells  that  form  the  hydro- 
chloric acid. 

Discuss  the  action  of  the  gastric  juice  on  carbohydrates 
and  fats. 

The  gastric  juice  has  no  effect  on  fats,  except  to  melt  some 
of  them  because  of  its  temperature. 

As  to  the  carbohydrates  starch  is  unaffected,  but  the  hy- 
drochloric acid  possibly  inverts  some  of  the  cane  sugar  pres- 
ent in  the  food. 

Give  the  composition  and  uses  of  blood. 

The  blood  is  composed  of  60  parts  plasma  and  40  parts 
corpuscles. 

In  a  thousand  parts  of  plasma  ninety-eight  are  solid.  The 
bulk  of  the  solid  matter  is  composed  of  the  proteids,  serum 
albumin,  serum  globulin  and  fibrinogen.  Besides  these  we 
have  various  salts,  especially  compounds  of  sodium,  calcium, 
potassium  and  magnesium  in  combination  with  chlorine,  phos- 
phorus and  carbon  dioxide.  There  are  also  fats,  urea,  uric 
acid,  dextrose  and  cholesterin. 

The  red  corpuscles  are  composed  of  water  69%,  hemoglobin 
29%,  and  small  quantities  of  other  proteids,  salts  and  ex- 
tractives. 

The  white  corpuscles  contain  globulin,  albumin,  nuclein, 
various  salts  and  the  mother  body  of  fibrin  ferment. 


PHYSIOLOGY.  247 

The  blood  carries  the  absorbed  food  and  oxygen  to  the 
tissues  and  carries  away  waste  to  the  organs  excreting  them. 
It  also  equalizes  the  temperature  of  the  various  parts  of  the 
body. 

Describe  the  process  of  absorption  by  (a)  the  blood= 
vessels,   (b)  the  lymphatics. 

The  digested  food  is  carried  through  the  columnar  epithe- 
lium of  the  intestinal  villi  by  the  force  of  osmosis  and  the 
vital  activity  of  the  cells,  the  peptones  being  changed  during 
their  passage  into  albumins  and  globulins.  The  carbohy- 
drates, soluble  salts  and  proteids  pass  into  the  capillaries 
and  then  on  into  the  portal  vein,  which  carries  them  to  the 
liver.  From  here  they  pass  out  through  the  hepatic  vein  into 
the  general  circulation.  The  fats  are  taken  up  by  the  lacteals 
and  carried  to  the  receptaculum  chyli  and  then  up  through 
the  thoracic  duet  into  the  left  subclavian  vein. 

Describe  the  red  blood  corpuscles.  Give  the  best  known 
and  most  important  function  of  the  red  blood  corpuscles. 

The  red  corpuscles  are  non-nucleated,  elastic,  biconcave 
discs  about  one  thirty-two  hundredth  of  an  inch  in  diameter. 
They  are  yellowish-green  when  seen  under  the  microscope. 
In  large  masses  they  are  red.  They  carry  the  oxygen  to  the 
tissues.  They  consist  of  a  stroma  in  which  is  imbedded  the 
hemoglobin. 

Describe  the  structure  of  the  arteries.  How  do  arteries 
exercise  their  function? 

The  arteries  have  three  coats — tunica  intima,  media  and 
adventitia.  The  intima  or  internal  coat  consists  of  a  lining 
of  a  single  layer  of  endothelial  cells  and  a  layer  of  yellow 
elastic  tis.sue.  The  media  or  middle  coat  is  composed  espec- 
ially of  involuntary  muscular  fibers  arranged  transversely 
to  the  long  axis,  but  it  also  contains  many  elastic  fibers.  The 
adventitia  or  outer  coat  is  made  up  of  a  supporting  layer  of 
areolar  tissue  in  which  are  many  yellow  elastic  fibers. 


248  PHYSIOLOGY. 

In  the  media  we  find  many  little  ganglionic  masses,  the 
local  vasomotor  system.     In  these  the  vasomotor  nerves  end. 

The  arteries  exercise  their  function  on  account  of  being 
closed  tubes,  by  reason  of  their  contained  elastic  tissue,  and 
by  the  action  of  the  vasomotor  influence  of  the  nervous  sys- 
tem on  the  muscular  fibers. 

Describe  the  fetal  circulation. 

The  blood  coming  from  the  placenta  through  the  umbilical 
vein  passes  into  the  inferior  vena  cava,  some  of  it  passing 
first  into  the  liver  by  the  ductus  venosus  and  then  into  the 
inferior  vena  cava.  It  is  then  carried  into  the  right  auricle, 
where  it  meets  the  blood  returning  by  the  superior  vena  cava 
from  the  head  and  upper  extremities. 

The  currents  do  not  mix  to  any  extent,  but  by  means  of  the 
Eustachian  valve  the  blood  from  the  inferior  vena  cava  flows 
through  the  foramen  ovale  into  the  left  auricle,  where  it 
meets  the  small  amount  of  blood  eoming  from  the  lungs  and 
is  passed  on  into  the  left  ventricle  and  out  through  the  aorta 
to  supply  especially  the  head  and  arms. 

The  blood  from  the  superior  vena  cava  passes  through  the 
right  auricle  into  the  right  ventricle  and  then  out  through 
the  pulmonary  artery.  Some  of  this  blood  passes  to  the  lungs, 
but  most  of  it  passes  through  the  ductus  arteriosus  into  the 
descending  aorta,  where  it  mixes  with  the  blood  from  the  left 
ventricle  and  supplies  the  lower  extremities,  a  portion  pass- 
ing through  the  umbilical  arteries  to  the  placenta. 

Mention  the  erectile  tissues  of  the  body  and  explain 
their  function. 

The  erectile  tissues  of  the  body  are  the  penis,  clitoris, 
nipples,  and  according  to  some,  the  mucous  membrane  of 
nose.  They  are  concerned  in  the  genital  sense,  increasing  the 
sexual  excitement  and  helping  complete  orgasm. 

What  digestive  changes  take  place  in  (a)  the  small  in= 
testines,  (b)  the  large  intestines? 

In  the  small  intestines  proteids  are  changed  into  peptones 


PHYSIOLOGY.  249 

and  even  lower  bodies,  such  as  tyrosin  and  leucin ;  fats  are 
split  up,  saponified  and  emulsified;  undigested  starch  is 
changed  into  maltose,  which  in  turn  is  changed  into  dextrose, 
and  cane  sugar  is  inverted. 

In  the  lower  part  of  the  small  intestine  and  in  the  large 
intestine  microbic  digestix)n  is  carried  on  with  the  forma- 
tion of  putrefaction  products,  carbon  dioxide,  methane,  hy- 
drogen sulphide,  hydrogen,  indol,  skatol,  phenol,  butyric  acid, 
valerianic  acid,  leucin,  tyrosin,  trimethylamine,  and  many 
other  products. 

Describe  the  structure  of  (a)  striated  muscle,  (b)  non= 
striated  muscle.  Which  of  these  is  called  voluntary,  and 
why? 

Striated  muscle  is  composed  of  fibers  transvereely  striated. 
Each  fiber  is  afcout  one  inch  long  and  one  five-hundredth  of 
an  inch  in  diameter. 

The  fibers  consist  of  an  outside  sheath  or  sarcolemma,  which 
is  filled  with  a  liquid,  the  sarcoplasm.  Imbedded  in  this  we 
find  the  muscle  columns  of  sarcostyles.  These  are  divided  by 
a  Kraus  membrane  into  sarcomeres,  each  of  which  is  com- 
posed of  a  central  dark  portion,  the  sarcous  element,  and  on 
either  side  a  lighter  portion. 

Non-striated  muscle  is  formed  of  small  spindle-shaped 
nucleated  cells,  not  transversely  striated.  It  has  some  faint 
longitudinal  striations. 

Striated  muscle  is  voluntary,  that  is,  under  the  control  of 
the  will. 

Define  reflex  nervous  action.     Give  examples. 

A  refiex  action  is  an  aflt'erent  impulse  followed  by  an  ef- 
ferent impulse  independent  of  the  higher  cerebral  centere. 
A  blow  in  the  solar  plexus  causes  an  inhibition  of  the  heart. 
The  testicle  retracts  when  tlie  inner  surface  of  thigh  is  stroked. 

Describe  the  rods  and  cones  of  the  retina. 

Tbc  layer  of  rods  and  cones  of  the  retina  is  the  ninth  and 
is  separated  from  the  choroid  by  the  tenth  or  pigment  layer. 


250  PHYSIOLOGY. 

The  rods  are  more  abundant  than  the  cones,  about  five  to  one, 
but  are  absent  in  the  fovea  centralis,  the  cones  only  being 
present.  In  the  outer  end  of  the  rods  the  visual  purple  is 
found.  The  cones  are  shorter  than  the  rods  and  contain 
no  visual  purple.  The  optic  nerve  ends  in  these  rods  and 
cones,  which  are  the  active  receptive  organs-  of  sight. 

Describe  the  sphygmograph  and  state  its  use. 

The  sphygmograph  or  pulse  recorder  essentially  consists  of 
a  spring  fastened  at  one  end,  wth  a  button  on  the  other 
end  to  press  on  the  artery,  and  a  system  of  fine  levers  so  ad- 
justed as  to  write  the  movements  of  the  spring  on  strips  of 
glazed,  blackened  paper. 

How  is  accommodation  in  the  eye  accomplished? 

Accommodation  is  accomplished  by  the  contraction  of  the 
ciliary  muscle  relaxing  the  suspensory  ligament  and  thus  al- 
lowing the  crystalline  lens  to  become  more  convex,  which  it 
then  does  on  account  of  its  elastic  capsule. 

How  do  veins,  arteries  and  capillaries  differ  as  to  (a) 
structure,  (b)  function? 

The  arteries  have  three  coats,  and  contain  more  muscular 
and  elastic  tissue  than  do  the  veins.  The  arteries  have  no 
valves,  while  many  of  the  veins  have.  The  capillaries  are 
formed  of  a  single  layer  of  lance-shaped  endothelial  cells. 

The  arteries  carry  the  blood  from  the  heart  to  the  capil- 
laries. The  veins  carry  it  back  to  the  heart.  Through  the 
capillary  wall  osmosis  and  diapedesis  occur;  thus  the  tissues 
are  nourished  and  the  waste  matter  is  carried  off. 

What  is  the  function  of  each  class  of  foods  in  the  nutri- 
tive process? 

The  proteids  repair  the  tissue;  the  carbohydrates  are  the 
body  fuel,  being  easily  oxidized;  the  fats  are  not  so  readily 
oxidized  but  are  used  up  to  form  heat,  the  excess  being  stored 
in  the  adipose  tissue;  the  salts  are  necessary  to  keep  some 
of  the  proteids  in  solution,  to  regulate  osmosis,  to  neutralize 


PHYSIOLOGY.  251 

the  acid  produced  by  katabolism,  to  form  bone,  and  are  a 
necessary  ingredient  in  most  of  the  secretions. 

State  the  origin  and  the  use  of  (a)  lymph,  (b)  the  bile. 

Lymph  is  the  diluted  blood  plasma  that  has  osmosed 
through  the  capillary  wall,  and  to  which  is  added  lymphocytes 
formed  in  the  lymphatic  glands.  It  bathes  and  nourishes  the 
tissues,  carries  away  waste  and  adds  lymphocytes  to  the  blood. 
The  products  of  some  of  the  ductless  glands  are  emptied 
into  it. 

The  bile  is  formed  in  the  liver.  Bile  neutralizes  the  acid 
chyme,  precipitating  the  pepsin,  aids  in  the  emulsification  and 
absorption  of  fats,  increases  peristalis,  and  contains  some 
waste  products. 

In  what  manner  is  the  heart=beat  influenced  by  the 
pneumojfastric  nerve?  What  is  the  average  number  of 
heart=beats  per  minute  in  (a)  a  child  aged  one  year,  (b) 
an  adult  aged  seventy  years? 

Stimulation  of  the  pneumogastric  nerve  causes  a  slowing 
of  the  heart. 

The  average  number  of  heart-beats  at  one  year  of  age  is 
about  115:  at  seventy  years  of  age,  about  70. 

Define  emulsification,  saponification.     Illustrate. 

Emulsification  is  the  breaking  up  of  a  fat  into  very  small 
particles  and  holding  them  in  suspension  in  a  liquid  in  which 
thej^  will  not  dissolve,  as  shaking  together  bile,  water,  and 
olive  oil. 

Saponification  is  the  replacing  of  the  glycerin  of  a  fat  by 
an  alkali,  as  by  the  heating  together  of  olein  and  sodium 
hydrate  to  form  sodium  oleate  and  glycerin. 

What  causes  an  increased  flow  of  bile  into  the  duo- 
denum? What  pathologic  effects  may  ensue  because  of 
occlusion  of  the  ductus  communis  choledochus? 

The  act  of  digestion  causes  an  increased  flow  of  bile  into 
the  duodenum,   as   will   also  certain   drugs,   as  calomel   and 


252  PHYSIOLOGY. 

podophyllin,   and  irritation  of  the  intestinal  mncous   mem- 
brane. 

Occlusion  of  the  ductus  communis  choledochus  is  followed 
by  jaundice  with  its  tendency  to  malaise,  headaches,  anaemia 
and  slowing  of  the  heart's  action.  It  also  interferes  with  the 
digestion  and  absorption  of  fats,  allows  of  an  excess  of  putre- 
factive substances  being  formed  in  the  intestines,  and  also 
causes  constipation. 

State  the  function  of  the  third  cranial  nerve.  What  is 
the  effect  of  division  of  the  third  cranial  nerve? 

The  third  nerve  is  the  motor  nerve  for  the  internal  rectus^ 
superior  rectus,  inferior  rectus,  inferior  oblique,  levator  palpe- 
brarum, ciliary  muscle  and  the  constrictor  of  the  pupil.  Sec- 
tion of  this  nerve  causes  loss  of  accommodation,  ptosis,  ex- 
ternal or  divergent  squint  and  diplopia. 

What  are  the  movements  of  the  eyeball?  Mention  the 
muscles  concerned  in  each  of  the  movements. 

Protrusion — caused  by  the  muscular  fibers  in  the  capsule 
of  Tenon. 

Retraction — caused  by  the  tight  closing  of  the  lids  or  paral- 
ysis of  the  muscular  fibers  in  the  capsule  of  Tenon. 

Upward  movement — caused  by  contraction  of  superior  rec- 
tus and  inferior  oblique. 

Downward  movement — caused  by  contraction  of  inferior 
rectus  and  superior  oblique. 

Inward  movement — caused  by  contraction  of  internal 
rectus. 

Outward  movement — ^caused  by  contraction  of  external 
rectus. 

Rotary  movement — caused  by  contraction  of  either  of  the 
two  oblique  muscles. 

What  are  the  accepted  theories  as  to  the  origin  of  (a) 
the  red  blood  corpuscles,  (b)  the  white  corpuscles? 

The  red  corpuscles  are  formed  in  the  red  marrow  of  bones 
and  in  the  spleen. 


PHYSIOLOGY.  253 

The  white  corpuscles  are  formed  in  the  lymphatic  system, 
the  spleen  and  the  marrow  of  bones. 

How  is  the  diaphragm  affected  in  expiration?  State 
cause. 

The  central  tendon  of  the  diaphragm  is  drawn  upward  into 
the  thorax  during  expiration  by  elastic  recoil  of  the  lungs, 
tending  to  produce  a  vacuum  in  the  pleural  cavity. 

Define  secretion,  excretion,  protoplasm,  assimilation. 

A  secretion  is  that  product  of  glandular  activity  needed 
in  the  various  processes  of  the  living  organism. 

An  excretion  is  that  product  of  glandular  activity  con- 
taining waste  of  no  further  use  to  the  organism. 

Protoplasm  is  the  living  substance  surrounding  a  specially 
formed  element  called  the  nucleus. 

Assimilation  is  the  conversion  into  protoplasm  of  nutrient 
material  or  food  ingested. 

What  are  the  causes  of  the  apex  beat  of  the  heart? 

The  apex  being  free  it  is  brought  forward  to  strike  against 
the  chest  wall  by  the  contraction  of  the  ventricle.  The  shock 
of  the  contracting  muscle  also  contributes  to  it. 

What  special  use  does  each  of  the  following  serve  in  the 
body  after  ingestion:  proteids,  fats,  carbohydrates,  alco= 
hoi,  tea  and  coffee? 

Proteids  repair  the  tissues,  fats  are  used  for  body  fuel  and 
as  a  reserve,  carbohydrates  are  the  body  fuel,  alcohol  in 
small  doses  is  a  general  stimulant  and  by  irritating  the 
mucous  membrane  causes  an  increased  flow  of  gastric  juice. 
Tea  and  coffee  are  stimulants,  increasing  the  flow  of  the 
various  secretions  and  stimulating  peristalsis. 

State  the  functions  of  the  fifth  cranial  nerve. 

The  fifth  nerve  is  the  sensory  nerve  of  the  face,  mouth 
and  nasal  cavities,  and  the  motor  nerve  of  the  muscles  of 
mastication. 


254  PHYSIOLOGY. 

What  effect,  if  any,  results  from  the  division  of  (a)  a 
vasoconstrictor  nerve,  (b)   a  vasodilator  nerve? 

Division  of  a  vasoconstrictor  nerve  causes  a  vasodilation 
in  the  part  it  supplies. 

Division  of  a  vasodilator  nerve  usually  has  no  ett'ect.  If 
it  be  in  action  at  the  time,  a  vasoconstriction  would  follow. 

Describe  the  vermicular  movement  of  the  stomach  and 
intestines.     What  purpose  does  this  movement  serve? 

The  movement  of  the  stomach  causes  the  food  there  to  be 
thoroughly  mixed,  the  peculiar  contraction  causing  a  current 
down  along-  the  fundus  to  the  pylorus  and  back  again  along 
the  lesser  curvative. 

The  movement  of  the  intestines  is  a  true  peristaltic  one,  that 
is,  one  segment  of  the  intestinal  walls  contracts  after  the 
preceding  segments ;  thus  a  wave  of  contraction  passes  down, 
mixing  an^  pressing  the  food  on  downward. 

Differentiate  white  fibrous  tissue  and  yellow  elastic 
tissue  as  to  (a)  structure,  (b)  distribution. 

White  fibrous  tissue  consists  of  white  fibers  arranged  in 
parallel  bundles,  the  connective  tissue  cells  also  being  ar- 
ranged in  this  way.  Yellow  elastic  tissue  is  a  connective 
tissue  in  which  the  yellow  fibers  predominate.  These  fibers 
are  larger  than  the  white  and  are  bound  together  with  areolar 
tissue.  The  white  fibrous  tissue  is  found  where  strength  and 
inelasticity  is  needed,  as  in  the  ligaments  and  tendons. 

The  yellow  fibrous  tissue  is  found  where  elasticity  is 
needed,  a.s  in  the  coats  of  blood  vessels,  in  the  lungs,  and 
vocal  cords. 

Explain  the  action  of  the  anospinal  center  in  defecation. 

The  anospinal  center  is  the  reflex  center  for  defecation. 
Irritation  of  the  mucous  membrane  of  the  rectum  sends  an 
impression  to  the  anospinal  center,  which  then  causes  a  re- 
laxation of  the  sphincter  muscles  and  an  increase  in  peris- 
talsis. This  center  is  under  the  control  of  the  will  to  a  great 
extent. 


FHYSIOLOGY.  255 

How  is  the  venous  blood  current  maintained?  What 
arteries  carry  venous  blood? 

The  venous  flow  is  maintained  by  the  vis  a  tergo,  or  force 
of  the  heart  carried  through  the  capillaries,  by  the  play  of 
the  valves  in  the  veins  during  muscular  movements,  and  by 
thoracic  and  intracardiac  action.  The  pulmonary  arteries 
carry  venous  blood. 

What  causes  the  difference  in  pitch  between  male  and 
female  voices?  What  causes  the  voice  of  the  youth  at 
the  period  of  puberty  to  "  crack  "? 

The  male  vocal  cords  are  longer,  hence  the  lower  pitched 
voice. 

The  cause  of  the  cracking  of  voice  at  puberty  is  the  change 
from  the  childish  treble  to  the  lower  adult  voice,  causing 
now  and  then  a  treble  tone  to  be  put  in. 

What  is  the  function  of  connective  tissue? 

The  connective  tissue  acts  as  a  binding,  supporting,  con- 
necting and  protecting  tissue  for  the  more  delicate  tissues 
and  organs. 

What  is  (a)  an  efferent  nerve,  (b)  an  afferent  nerve? 
Illustrate. 

An  efferent  nerve  is  one  carrying  impulses  from  the  cen- 
tral nervous  sytem  to  the  various  parts  of  the  body.  The 
facial  nerve  carries  motor  impulses  from  the  central  nervous 
system  to  the  muscles  of  expression. 

An  afferent  nerve  is  one  carrying  impulses  to  the  central 
nervous  system  from  the  various  parts  of  the  body.  The 
optic  nerve  carries  impressions  received  on  the  retina  to  the 
brain. 

Describe  the  glands  and  villi  of  the  intestines. 

In  the  intestines  we  find  two  sets  of  glands,  Brunner's 
and   rjiolierkuhti's. 

The  glands  of  Brunner  are  branched  convoluted  tubular 
glands  found  dipping  down  in  the  mucous  membrane  of  the 

diindciiuiii  oiilv. 


256  PHYSIOLOGY. 

The  crypts  of  Lieberkuhn  are  little  tubular  depressions  in 
the  mucous  membrane  of  both  the  small  and  large  intestines. 
They  are  larger  in  the  large  intestine.  They  consist  of  a 
basement  membrane  lined  with  columnar  and  goblet-shaped 
epithelial  cells. 

The  villi  are  small  nipple-like  projections  from  the  mucous 
membrane  of  the  small  intestines  about  one-thirtieth  of  an 
inch  long. 

A  villus  consists  of  a  mass  of  adenoid  tissue  covered  with 
a  layer  of  columnar  epithelium  resting  on  a  basement  mem- 
brane. In  the  center  of  this  adenoid  tissue  we  find  a  little 
lymphatic  called  a  lacteal.  We  also  find  in  the  adenoid  tissue 
many  capillaries  which  coalesce  to  form  the  venules  of  the 
mesenteric  veins. 

Describe  the  movements  of  the  blood  corpuscles  in  the 
capillaries  and  explain  the  phenomena  of  diapedesis. 

The  capillaries  are  on  an  average  just  large  enough  to  al- 
low the  red  corpuscles  to  pass  through.  In  passing  through 
some  of  the  capillaries  they  are  altered  somewhat  in  shape, 
but  on  account  of  their  elastic  stroma  immediately  resume 
their  shape  when  the  pressure  is  removed.  As  they  have  to 
flow  along  in  single  file  at  juncture  of  two  capillaries  to  form 
one,  they  take  alternate  turns  in  passing  into  it. 

The  white  corpuscles  tend  to  adhere  to  the  wall  and  do 
not  move  as  rapidly  as  the  red  ones. 

In  diapedesis  the  white  corpuscle  pushes  one  of  its  pseu- 
dopodia  through  the  cement  substance  of  the  cells  of  the 
capillary  wall,  and  then  pulls  the  rest  of  the  body  through 
after  it. 

Mention  three  varieties  of  cells  according  to  situation 
in  the  body. 

Epithelial  cells  are  found  in  the  skin. 

White  corpuscles  are  found  in  the  blood. 

Nerve  cells  are  found  in  the  central  nervous  system. 


PHYSIOLOGY.  257 

"What  is  the  mode  of  production  of  heat  in  the  body? 

Heat  is  produced  by  the  chemical  action  going  on  in  the 
tissues,  especially  in  the  muscular  and  glandular  tissues. 

Describe  cholesterin,  g^iving  its  origin  and  function. 

Cholesterin  is  a  monatomic  alcohol  found  especially  in  the 
nervous  tissue,  and  thrown  off  in  small  quantities  from  the 
body  in  bile.  It  is  possibly  a  waste  product  of  the  nervous 
tissue. 

Mention  and  describe  three  varieties  of  cells  according 
to  shape. 

Involuntary  muscular  fibers  are  small  spindle-shaped  cells, 
•containing  about  their  center  an  oval  nucleus.  They  are 
faintlv  striated  longitudinally. 

Squamous  epithelial  cells  are  flat  scale-like  cells,  having 
A  small  nucleus  near  their  center. 

White  blood  corpuscles  are  nucleated  granular  masses  of 
protoplasm,  about  one  twenty-five-hundredth  of  an  inch  in 
■diameter.  At  rest  they  are  globular,  but  during  ameboid 
movement  are  irregular  in  shape. 

Mention  the  ductless  glands  and  give  the  theory  as  to 
the  function  of  any  one  of  them. 

The  ductless  glands  are  the  thyroid,  thymus,  adrenals, 
spleen,  pituitary  body,  coccygeal  and  (?arotid.  Many  other 
organs  have  also  internal  secretion. 

The  adrenal  secretion  has  a  marked  influence  over  vaso- 
motor and  general  muscular  tone. 

How  is  the  sensation  of  sound  conveyed  to  the  brain? 

It  is  conveyed  from  the  cochlea  by  the  auditory  nerve  to 
the  medulla,  then  to  the  superior  olive,  through  lateral  fillet 
to  the  posterior  <|uadrigeminal  bodies  to  the  cerebral  cortex. 

What  matters  are  excreted  by  the  skin?  How  may  the 
function  of  the  skin  be  affected  as  to  the  amount  of  ex- 
cretion? 

The  sweat  contains  one  per  cent,  of  solid  matter,  in  which 
17 


258  PHYSIOLOGY. 

we  find  sodium  chloride  and  other  inorganic  salts,  urea,  fatty 
acids  and  coloring  matter. 

The  function  of  the  skin  may  be  affected  physiologically 
by  increased  urination  and  diarrhoea,  by  reflex  irritation  of 
sweat  centers,  by  the  emotions,  by  increase  of  body  tempera- 
ture calling  for  more  heat  dissipation,  and  by  the  accumula- 
tion of  carbon  dioxide  in  the  blood.  Ingestion  of  many  drugs 
also  affects  the  excretion. 

Mention  some  of  the  exercises  that  injuriously  affect 
the  heart.     State  the  reasons  for  your  conclusion. 

Among  exercises  that  injuriously  affect  the  heart  are 
wrestling,  long-distance  racing,  bicycle  racing  and  rowing 
matches,  the  bad  effect  being  due  to  the  sudden  strain  which 
causes  dilatation  and  hypertrophy  of  the  heart. 

State  the  function  of  the  retina. 

The  retina  is  the  receptive  nervous  organ  of  sight. 

What  are  the  physiologic  characteristics  of  protoplasm? 

Protoplasm  has  the  power  of  nutrition,  growth,  reproduc- 
tion, movement  and  response  to  stimuli. 

What  is  the  usual  difference  in  shape  between  the  red 
corpuscles  of  the  blood  in  the  mammalia  and  those  in 
the  ovipara? 

With  the  exception  of  the  camels,  mammalian  red  cor- 
puscles are  non-nucleated,  'biconcave,  circular  discs.  In  the 
ovipara  they  are  nucleated,  oval  and  biconvex. 

State  the  changes  in  the  diameter  of  the  chest  in  in= 
spiration   and   expiration. 

In  inspiration  the  vertical  diameter  is  increased  by  the 
descent  of  the  diaphragm;  the  anteroposterior  and  trans- 
verse diameters  are  increased  by  the  raising  and  rotation  of 
the  ribs  anteriorly  and  laterally. 

The  reverse  occurs  during  expiration. 

The  circumference  of  the  chest  is  increased  in  forced  in- 
spiration from  2  to  5  or  6  inches  over  forced  expiration. 


PHYSIOLOGY.  259 

Explain  the  anatomic  and  physiologic  difference  between 
mucous,  serous,  and  synovial  membrane. 

Mucous  membranes  are  secreting  membranes  lining  cavities 
opening  into  the  air  and  composed  of  one  or  more  layers  of 
epithelial  cells. 

Serous  membranes  are  those  lining  closed  sacs  belonging 
to  the  lymphatic  system  and  composed  of  a  single  layer  of 
flat  endothelial  cells  on  a  basement  membrane. 

Synovial  membranes  are  those  lining  closed  sacs  or  bursoe 
in  joints  or  over  tendons.  They  secrete  synovia,  which  favors 
free  motion  by  preventing  friction. 

Describe  the  physical  properties  of  healthy  urine. 

Healthy  urine  is  a  straw  yellow,  acid,  clear  liquid,  with 
a  specific  gravity  of  1015  to  1025,  and  with  characteristic  odor. 
On  standing,  a  slight  sediment  collects  in  the  lower  part  of 
the  liquid. 

Describe  the  changes  in  form  and  volume,  and  in  physi- 
cal and  chemical  properties,  occurring  in  the  contraction 
of  a  muscle. 

The  muscle  becomes  shorter,  but  the  volume  remains  the 
same.  It  becomes  acid  in  reaction,  more  oxygen  is  used  up 
and  more  carbon  dioxide  given  off,  sarcolactic  acid  is  gen- 
erated, glycogen  is  used  up,  and  the  muscle  substances  soluble 
in  water  are  diminished  in  amount,  while  those  soluble  in 
alcohol  are  increased. 

Locate  in  the  brain,  the  seat  of  the  special  sense  of 
sight,  hearing  and  smell. 

Sight  has  its  seat  in  the  gyrus  angularis,  cuneus,  and  in 
the  occipital  lobes;  hearing  in  the  superior  temporal;  smell 
in  the  uncus. 

Explain  the  phenomena  and  causation  of  auditory  ver- 
tigo or  Meniere's  disease. 

It  is  due  to  some  disturbance  or  abnormal  irritation  of  the 
endings  of  the  vestibular  branch  of  the  auditory  nerve.  This 
branch  normally  sends  impressions  to  the  nucleus  fastigii  in 


260  PHYSIOLOGY. 

the  cerebellum  which  help  to  control  the  balancing  and  co- 
ordination of  the  muscles  of  the  body. 

How  do  the  striped  and  unstriped  muscular  fibers  differ 
in  response  to  stimuli? 

The  unstriped  muscular  fibers  are  much  slower  in  response. 

What  is  the  order  of  occurrence  of  rigor  mortis  in  the 
different  parts  of  the  body? 

Rigor  mortis  usually  begins  in  the  muscles  of  the  eye, 
passing  to  the  jaw  and  neck  muscles,  and  in  turn  to  the 
chest,  arms,  abdomen  and  lower  extremities. 

What  relation  does  the  nervous  system  bear  to  the  ex= 
cretion  of  perspiration? 

The  nervous  system  through  the  sweat  centers  regulates  the 
tjxcretion  of  perspiration. 

What  portion  of  the  cerebrum  comprises  the  motor  area? 

The  motor  area  is  found  along  the  fissure  of  Rolando  in 
♦;ne  ascending  parietal,  ascending  frontal  and  paracentral  con- 
volutions and  contiguous  parts  of  the  superior  frontal. 

Give  the  presumptions  of  survivorship  and  reasons 
therefor  in  the  following  from  Casper:  A  is  killed  by  a 
thrust  of  a  saber  on  the  head;  B  by  that  of  a  bayonet  in 
the  heart;  and  C  by  a  shot  which  has  torn  open  the  jug= 
ular  vein. 

If  A's  injuiy  involved  especially  the  base  of  the  brain  the 
shock  of  the  injury  would  probably  cause  instant  death. 

B  would  probably  be  the  second  to  die,  probably  living  at 
least  a  half  hour  until  the  giving  out  of  the  heart  from 
pressure  of  the  blood  in  the  pericardium. 

C  would  be  the  last  to  die,  as  lacerated  wounds  of  even 
large  vessels  often  stop  spontaneously,  and  his  bleeding  might 
be  checked  by  pressure  until  surgical  help  arrived. 

Define  the  function  of  the  mucous  membrane  of  the 
respiratory  tract. 

The  mucous  membrane  of  the  respiratory  tract  secretes  a 


PHYSIOLOGY.  261 

protecting  mucus,  and  because  of  its  ciliated  epithelial  cells 
keeps  the  lungs  clear  of  accumulation  of  mucus  and  small 
dirt  particles  entering  with  the  inspired  Jiir.  The  vital 
activity  of  the  squamous  cells  lining  the  air  vesicles  aids  in 
the  exchange  of  the  respiratory  gases. 

In  what  glands  of  the  body  is  the  function  undeter= 
mined? 

With  the  exception  of  being  able  to  say  that  they  are  all 
probably  connected  with  general  metabolism,  the  functions 
of  the  following  glands  are  undetermined :  Pituitary  body, 
thymus,  coccygeal  gland.  But  little  is  known  about  the 
adrenals  and  thyroids. 

What  is  the  normal  ratio  of  respirations  to  heart  pul=» 
sation? 

In  a  healthy  adult  there  are  four  pulse  beats  to  one  respira- . 
lion. 

Give  the  foramen  of  exit,  the  distribution  and  the  func- 
tion of  the  oculomotor  nerve. 

The  oculomotor  nerve  leaves  the  skull  through  sphenoidal 
fissure.  It  supplies  motor  filaments  to  the  superior,  internal, 
and  inferior  recti,  the  inferior  oblique,  the  levator  palpebrae, 
the  ciliary  muscle  and  the  constricting  fibers  of  the  iris. 

What  office  does  the  Eustachian  tube  perform? 

It  equalizes  the  pressure  of  the  air  on  the  membrana- 
tympani,  thus  facilitating  hearing. 

Define  leucomain. 

Leucomains  are  alkaloidal  or  basic  substances  formed  in 
the  living  tissue  by  metabolism.  They  are  normally  removed 
from  the  body  in  the  excretions. 

Give  the  present  physiolojfic  conclusions  in  respect  to 
the  presence  of  the  corpus  luteum  as  a  sign  of  pregnancy. 

According  to  Tidy,  "  there  may  be  pregnancy  without  the 
presence  of  a  true  corpus  luteum,  and  also  bodies  indis- 
tinguishable from  true  corpora  lutea  may  be   found  where 


262  PHYSIOLOGY. 

there  has  been  no  pregnancy."     The  presence  of  the   true 
corpus  luteum  nevertheless  is  usually  a  sign  of  pregnancy. 

What  effects  are  produced  in  the  system  by  the  removal 
of  the  thyroid  gland? 

Removal  of  the  thyroid  gland  is  followed  by  peculiar  de- 
praved condition  of  metabolism  called  cachexia  strumipriva. 

Give  the  principal  characteristics  of  gastric  juice  in  man. 

Gastric  juice  is  an  acid  limpid  secretion  with  a  specific 
gravity  of  about  1005,  quantity  ten  pints  daily.  It  contains 
essentially,  pepsin,  rennin  and  hydrochloric  acid. 

How  can  fresh  blood  stains  be  distinguished  from  older 
blood  stains? 

Fresh  blood  stains,  are  brighter  in  color  and  the  clot  is 
flexible ;  the  older  stain  is  darker  and  the  clot  is  fragile. 

Describe  color  blindness  and  name  the  colors  which  the 
subject  commonly  fails  to  distinguish. 

Color  blindness  is  the  inability  to  perceive  certain  colors. 
The  colors  commonly  indistinguishable  are  red  and  green. 

What  are  the  functions  of  the  brain  membranes? 

The  dura  mater  is  tough  and  protecting,  and  also  acts  as 
internal  periosteum  to  the  bones  of  the  head. 

The  arachnoid  is  a  thin  spider-like  membrane  covered 
with  endothelial  cells  that  secrete  cerebrospinal  fluid. 

The  pia  mater  is  a  vascular  membrane  dipping  down  into 
the  sulci  and  carrying  blood  to  the  cortex. 

Name  the  solids  in  the  urine  and  state  the  approximate 
amount  of  each  voided  daily  by  an  adult. 

Urea  500  grains;  chloride  of  sodium  180  grains;  sulphates 
(sodium  and  potassium)  30  grains;  phosphate  (earthy  and 
alkaline)  45  grains;  uric  acid  7  grains;  hippuric  acid  7 
grains;  and  small  quantities  of  various  pigments  and  other 
organic  matter. 


PHYSIOLOGY.  263 

Describe  the  factors  which  cause  the  heart  sounds. 

The  first  sound  is  due  to  muscular  contraction  and  to  the 
■closure  of  the  auriculo-ventricular  valves,  as  the  blood  tends 
to  regurgitate  into  the  auricles  during  ventricular  systole. 

The  second  sound  is  due  to  the  closure  of  the  semilunar 
valves,  the  blood  tending  to  regurgitate  into  the  ventricles 
during  diastole. 

What  is  the  effect  of  an  excessive  meat  diet? 

An  excessive  meat  diet  disturbs  the  general  metabolism, 
■causing  diseased  conditions  associated  -with  an  increase  in 
uric  acid,  as  gout,  rheumatism  and  migraine. 

Explain  how  the  seminal  fluid  is  conveyed  to  the  vesi= 
culae  seminales. 

It  is  conveyed  to  the  vesiculae  seminales  by  the  vas  defer- 
■ens,  which  is  the  prolongation  of  the  tube  forming  the  epi- 
didymis. The  vas  deferens  passes  up  from  the  testicles 
through  the  external  and  internal  abdominal  rings  and  to  the 
vesiculae  seminales  on  the  posterior  surface  of  the  bladder. 

How  and  why  is  hearing  affected  by  rupture  of  the 
membrana  tympani? 

The  membrana  tympani.  on  account  of  its  shape  and  the 
action  of  the  tensor  tympani,  is  capable  of  responding  to 
many  vibrations,  and  thus  aids  in  the  acuity  of  hearing. 

Describe  cell  growth. 

Cell  growth  is  that  peculiarity  which  living  cells  have  of 
taking  in  new  material  and  incorporating  it  into  themselves, 
thus  increasing  in  size. 

Describe  the  phenomena  of  (a)  asphyxia,  (b)  syncope, 
(c)   sleep. 

Asphyxia  is  the  condition  caused  by  a  deficient  supply  of 
oxygen.  In  the  complete  shutting  oft'  of  the  supply  of 
oxygen  we  have  three  stages.  First,  the  stage  of  marked  in- 
spiratory efforts  or  dyspnoea,  lasting  about  one  minute;  sec- 
ond, the  stage  of  convulsions  with  marked  expiratory  spasms, 


264  PHYSIOLOGY. 

lasting  about  one  minute;  and  third,  the  stage  of  exhaustioa 
and  finally  death. 

During  the  first  stage  the  'blood  pressure  begins  to  rise  and 
heart  becomes  somewhat  slower.  During  the  second  stage 
this  rise  in  blood  pressure  is  well  marked  and  also  the  slow- 
ing of  the  heart.  Toward  the  end  of  this  stage  as  the  re- 
spiratory movements  cease  unconsciousness  ensues,  the  blood- 
pressure  falls  and  the  heart  becomes  still  slower,  until  death 
stops  everything. 

Syncope  is  that  condition  of  unconsciousness  following  a 
sudden  depression  of  the  vasomotor  and  cardiac  nervous  me- 
chanism, causing  anemia  of  the  brain. 

Sleep  is  a  physiological  condition  of  unconsciousness,  due 
to  a  periodical  need  of  the  nervous  system  for  rest.  It  is 
also  due  in  part  to  the  absence  of  external  stimuli.  It  is  ac- 
companied by  an  anemia  of  the  brain. 

Name,  locate,  and  give  the  function  of  each  of  the  vari= 
eties  of  epithelia. 

Epithelium  secretes  and  protects  the  underlying  tissues. 
Squamous  epithelium,  found  in  the  mouth,  protects  the  un^der- 
lying  structures.  Columnar  epithelium,  found  in  the  intes- 
tinal mucosa,  aids  in  the  absorption  of  digested  food  products. 
Ciliated  epithelium,  found  in  the  bronchial  mucosa,  forces- 
dust  and  mucus  up  into  the  trachea  to  be  coughed  out. 
Cuboidal  epithelium,  found  in  the  salivary  glands,  secretes 
saliva.  Groblet-shaped  epithelium,  found  in  the  mucous  mem- 
branes, forms  the  mucous  secretion.  Stratified  epithelium  is 
composed  of  several  layers,  the  uppermost  generally  squa- 
mous, and  lowermost  columnar.     It  forms  the  epidermis. 

Describe  the  lymphatic  system. 

The  lymphatic  system  consists  of  numerous  small  thin- 
walled  vessels  with  many  valves,  commencing  in  the  tissues 
as  lymph  capillaries  and  emptying  into  two  larger  vessels, 
that  carry  the  contained  lymph  to  the  subclavian  veins.  In 
certain  places  along  the  eourse  of  the  lymphatics,  as  in- 
axilla    and   groin,    are  found   groups  of  little    glands   called; 


PHYSIOLOGY.  265 

lymphatic  glands.  These  consist  of  a  cortical  portion  and 
a  medulla  which  is  made  of  lymphoid  tissue,  in  the  center  of 
which  are  a  number  of  cells  rapidly  undergoing  karyokinesis. 
All  the  lymphatics  (including  the  lacteals  of  the  intestine) 
with  the  exception  of  right  half  of  the  body  from  the  dia- 
phragm upward,  empty  into  the  thoracic  duct.  This  vessel, 
about  the  diameter  of  a  goose  quill,  empties  into  the  left 
subclavian  vein.  The  lymphatics  of  the  right  side  of  the 
body  from  the  diaphragm  upward  empty  through  a  smaller 
vessel  into  the  right  subclavian  vein. 

Describe  the  olfactory  apparatus.  What'  part  of  the 
olfactory  apparatus  is  the  seat  of  smell? 

The  nasal  cavities  are  divided  into  a  lower  or  respiratory 
portion  and  an  upper  or  olfactory  portion. 

We  find  in  the  upper  portion  some  broad  supporting  epithe- 
lial cells,  and  projecting  upward  from  cells  between  these 
are  little  hair-like  processes.  The  olfactory  nerve  ends  in 
these  specialized  cells.  The  olfactory  nerve  passes  from  these 
cells  through  the  olfactory  bulbs  and  backward  through  three 
tracts  to  the  cerebrum,  ending  for  the  most  part  in  the  uncus 
of  the  same  side. 

What  is  the  physiology  of  the  so=caIIed  rest  cure? 

The  rest  cure  corrects  faulty  metabolism  and  brings  the 
tissues  again  to  their  normal  conditions. 

How  is  the  descent  of  the  testicle  to  the  scrotum  ac= 
complished? 

The  descent  of  the  testicle  is  now  generally  thought  to  be 
due  simply  to  the  arrangement  of  the  organs  due  to  the 
process  of  development  and  not  to  the  traction  of  nuiscular 
cord,  as  formerly  thought. 

Describe  the  growth  and  the  development  of  the  teeth. 

The  first  step  in  the  formation  of  the  teeth  is  the  down- 
ward growth  of  the  epithelium  covering  the  rudimentary  jaw. 
This  forms  the  enamel  germ,  which  develops  especially  at  cer- 
tain   points.      A    little    vascular    i>apilla    now    grows   upward 


266  PHYSIOLOGY. 

into  this  enamel  germ;  thus  we  have  the  rudimentary  teeth. 
The  adamantoblasts  of  the  enamel  germ  form  the  enamel,  and 
the  odontoblasts  form  the  dentine  which  covers  in  the  dental 
pulp.  The  crusta  petrosa  is  formed  from  the  cells  forming 
the  dental  periosteum. 

What  is  the  condition  of  the  eyeball  in  myopia?  How 
may  it  be  corrected? 

In  myopia  the  eyeball  is  too  deep,  causing  the  rays  of 
light  to  be  brought  to  a  focus  in  front  of  the  retina.  It  is 
corrected  by  a  concave  lens. 

Define  physiologically  the  term  cell.  How  are  cells  re= 
produced? 

A  cell  is  a  nucleated  mass  of  protoplasm. 
Cells  are  reproduced  by  direct  division,  indirect  division 
or  karyokinesis,  and  endogenous  nuclear  multiplication. 

Describe  the  physical  characteristics  of  cartilage.  What 
is  temporary  cartilage,  permanent  cartilage?     Illustrate. 

Cartilage  is  a  firm,  elastic,  white  or  yellow-white  substance. 

Temporary  cartilage  is  that  which  afterward  is  formed  into 
bone,  as  the  fetal  femur. 

Permanent  cartilage  is  that  which  remains  as  cartilage  dur- 
ing life,  as  articular  cartilage. 

Describe  the  white  blood  corpuscles,  giving  source,  com= 
position  and  properties. 

The  white  blood  corpuscles  are  nucleated  masses  of  granu- 
lar protoplasm,  about  ^s'oo  i°-  iii  diameter  and  capable  of 
amoeboid  movement  and  phagocytic  action. 

As  to  the  varieties,  we  find  the  small  lymphocyte,  the  larger 
transitional,  the  polymorpho-nuclear.  and  eosinophile  con- 
taining large  granules  staining  readily  with  eosin.  Occa- 
sionally a  basophile  can  be  found. 

The  white  cells  are  developed  from  the  lymphatic  tissues, 
the  spleen  and  the  marrow  of  bone.  Chemically  they  con- 
tain nuclein,  a  globulin,  fat,  glycogen  and  a  nucleoproteid. 


PHYSIOLOGY,  267 

What  changes  are  produced  in  the  air  and  in  the  blood 
by  respiration? 

The  expired  air  contains  less  oxygen  and  more  carbon  diox- 
ide, nitrogen,  and  water  than  inspired  air.  It  also  contains 
■certain  volatile  organic  substances  and  is  warmer  than  the 
inspired  air. 

The  blood  leaving  the  lungs  contains  more  oxygen  and  less 
•carbon  dioxide  and  nitrogen  than  that  entering  the  lungs. 

Define  aphonia,  aphasia.  Give  the  cause  of  one  of  these 
conditions. 

Aphonia  is  the  loss  of  voice,  or  the  power  of  phonation. 

Aphasia  is  the  inability  to  give  the  proper  word  symbol. 

Motor  aphasia  is  due  to  a  lesion  of  the  left  lower  frontal 
■convolution  or  of  the  fibers  coming  from  it. 

Describe  the  normal  heart  sounds. 

The  first  sound  is  twice  as  long  as  the  second,  lower  in 
pitch  and  with  a  prolonged  dull,  somewhat  booming  quality. 
It  is  caused  by  the  closure  of  the  auriculo-ventricular  valves 
^nd  the  sound  of  contracting  muscular  walls  of  the  ventricles. 
It  is  heard  best  at  the  apex,  and  is  systolic  in  time. 

The  second  sound  follows  the  first  after  a  short  interval. 
It  is  short,  snapping  in  quality  and  is  higher  pitched  than 
the  first.  It  is  caused  by  the  closure  of  the  semilunar  valves 
and  is  diastolic  in  time.  It  is  heard  best  at  the  base  of  the 
heart. 

State  the  physiologic  uses  of  the  large  intestine. 

Into  the  large  intestine  the  crypts  of  Lieberkuhn  pour  in 
some  secretion  and  the  microbic  digestion  goes  on.  Although 
no  villi  are  found  here  part  of  the  food  not  already  absorbed 
is  taken  up.  The  feces  are  concentrated  and  collected  in  the 
lower  end  of  the  intestine,  to  be  expelled  during  the  act  of 
defecation. 

Define  (a)  tonic  muscular  contraction,  (b)  clonic  mus- 
cular contraction,     (jive   an  example  of  each. 

Tonic  muscular  contraction  is  a  continued  contraction,  as 
the  action  of  sphincter  ani. 


268  PHYSIOLOGY. 

Clonic  muscular  coutraction  is  au  iutermittent  or  remittent 
muscular  contraction  as  seen  in  the  jerking  movements  of  a 
convulsion. 

Define  reserve  air,  residual  air,  complemental  air,  tidal 
air. 

Reserve  air  is  the  amount  of  air  that  can  be  expired  after 
an  ordinary  expiration,  about  100  cubic  inches. 

Residual  air  is  the  amount  of  air  left  in  the  lungs  after 
the  most  forcible  expiration,  about  100  cubic  inches. 

Complemental  air  is  the  amount  of  air  that  can  be  taken  in 
after  an  ordinary  inspiration,  about  100  cubic  inches. 

Tidal  air  is  the  amount  of  air  taken  in  with  each  ordinary 
inspiration,  about  30  cubic  inches. 

What  are  the  respective  functions  of  the  anterior  and 
of  the  posterior  cornua  of  the  spinal  cord? 

The  anterior  cornua  are  motor  in  function  and  are  the 
trophic  centers  for  the  muscles. 

The  posterior  cornua  are  mostly  relay  stations  on  the  sen- 
sory pathway. 

What  explanation  may  be  g:iven  for  enlargement  of  the 
spleen  in  leucocythemia? 

The  spleen  is  one  of  the  organs  in  which  white  corpuscles 
are  formed. 

Give  the  difference  between  the  temperature  of  a  new= 
born  child  and  that  of  an  adult,  between  the  temperature 
of  a  person  intoxicated  by  alcoholic  drink  and  his  tem= 
perature  after  the  first  stimulating  drink  of  liquor. 

Immediately  after  birth  the  temperature  is  somewhat  above 
normal,  but  soon  becomes  subnormal.  At  the  end  of  twenty- 
four  hours  it  has  again  reached  normal  and  remains  so.  A 
small  dose  of  alcohol  causes  a  slight  rise  in  temperature ;  large 
doses,  as  in  one  intoxicated,  cause  a  subnormal  temperature. 

In  a  healthy  man,  what  time  is  consumed  in  the  diges= 
tion  of  an  ordinary  meal  of  meat,  vegetables  and  bread? 

The  food  remains  from  two  to  four  hours  in  the  stomach 


PHYSIOLOGY.  269 

and  about  six  hours  in  the  small  intestine.    Digestion  is  prac- 
tically finished  before  it  leaves  the  small  intestine. 

Define  human  physiology. 

Human  physiology  is  the  study  of  the  phenomena  of  the 
living  human  body. 

Give  the  causes  of  muscular  fatigue. 

Muscular  fatigue  is  caused  by  the  accumulation  of  waste 
products  in  the  musclies. 

The  seat  of  fatigue,  as  we  ordinarily  speak  of  it,  is  first  in 
the  central  nervous  system,  then  in  the  motor  end  plates, 
then  the  muscle  and  finally  the  nerve  trunks. 

What  effect  is  produced  on  the  heart's  action  by  stimu= 
lation  of  the  cardioinhibitory  center? 

There  is  a  slowing  of  the  heart,  or,  if  the  stimulus  is  great 
enough,  a  stoppage  of  the  heart  in  diastole. 

Why  does  blood  remain  fluid  in  the  body  in  life,  and 
coagulate  when  shed? 

The  intima  has  some  unknown  peculiar  action  on  the  blood. 
The  blooil  does  not  clot  until  the  disintegration  of  the  white 
corpuscles  sets  free  the  fibrin  ferment. 

What  conditions  produce  variations  in  the  normal  tem- 
perature of  the  body? 

Anything  that  will  disturb  the  proper  balance  of  heat  pro- 
duction and  heat  dissipation  will  cause  a  variation  from  the 
narmal  temperature. 

Normal  physiological  variations  are  caused  by  digestion, 
muscular  exercise,  raenstiiiation.  bathing  and  excitement. 

Drugs,  as  cocain,  atropine,  alcohol,  acetanilid.  may  cause 
variations  from  the  normal ;  as  will  also  hypodermic  injec- 
tions of  proteoses  and  peptones,  shock,  toxins  of  bacteria  and 
exposure  to  excessive  changes  in  temperature  of  atmosphere. 

Give  the  nervous  mechanism  of  urination. 

The  bladder  is  supplied  with  nerves  fi-om  the  lower  dorsal 


270  PHYSIOLOGY. 

and  upper  lumbar  nerves  and  also  with  branches  from  the 
sympathetic  system.  The  act  of  urination  may  be  completely 
involuntary,  the  reflex  center  being  in  the  lumbar  portion 
of  the  spinal  cord  and  set  in  action  by  afferent  impulses, 
from  a  distended  bladder  or  from  irritation  possibly  of  the 
mucous  membranes.  Ordinarily  the  abdominal  muscles  aid 
voluntarily  in  urination. 

There  is  probably  a  higher  voluntary  center  and  also  an 
inhibitory  one. 

Describe  the  human  blood. 

Blood  is  a  red,  alkaline  fluid,  salty  and  nauseating  in  taste, 
with  a  peculiar  odor.  It  has  a  specific  gravity  of  about  1055. 
It  is  composed  of  a  liquid  portion  called  plasma,  and  a  solid 
portion,  the  red  and  white  corpuscles.  In  the  plasma  we 
find  seruin  albumin  and  globulin,  fibrinogen,  various  salts, 
especially  sodium,  potassium  and  calcium,  and  small  quan- 
tities of  dextrose,  fats  and  extractives.  The  hemoglobin  is 
found  in  the  red  corpuscles. 

What  is  the  purpose  of  respiration?  Give  the  mechan= 
ism  of  respiration. 

During  the  act  of  respiration  oxygen  is  absorbed  and  car- 
bon dioxide  is  thrown  off. 

During  inspiration  the  diaphragm  descends,  the  ribs  are 
elevated  and  rotated  outward;  the  cavity  of  the  thorax  is. 
thus  enlarged  and  the  air  rushes  in  to  fill  up  the  partial 
vacuum ;  the  muscles  now  relax  and  the  elasticity  of  the  chest 
wall  and  lungs  forces  a  portion  of  the  air  out.  These  move- 
ments are  controlled  by  the  respiratory  center  in  the  medulla. 

How  is  bone  nourished? 

Bone  is  nourished  by  the  nutrient  arteries  through  the 
Haversian  system  of  canals  and  by  the  periosteum. 

State  the  function  of  the  anterior  spinal  nerve  roots^ 
How  is  the  function  proved? 

The  anterior  roots  are  motor. 


PHYSIOLOGY.  271 

Section  of  the  anterior  roots  causes  motor  paralysis  of 
the  parts  that  they  supply.  Irritation  of  the  peripheral  ends 
causes  contraction  of  the  muscles  they  supply.  Irritation  of 
central  ends  has  no  effect ;  no  sensation  is  felt. 

Give  illustration  of  morbid  reflex  action. 

The  vomiting  of  pregnancy  is  caused  reflexly  by  irritation 
of  mucous  membrane  of  uterus. 

Faulty  digestion  may  cause,  reflexly,  palpitation  of  the 
heart. 

What  is  the  composition  of  urine?  Give  the  normal  re= 
action  and  specific  gravity  of  urine. 

Urine  is  composed  of  96%  water  and  4%  solids,  one-half  of 
which  is  urea.  The  other  half  is  made  up  of  phosphates 
(earthy  and  alkaline),  sulphates  of  sodiura  and  potassium^ 
chloride  of  sodium,  uric  acid,  hippuric  acid,  extractives  and 
the  coloring  matters — indican,  urobilin  and  urochrome. 

The  normal  reaction  of  urine  is  acid  and  the  specific  grav- 
ity 1020. 

Describe  the  temporary  and  permanent  teeth. 

The  temporary  or  milk  teeth  are  twenty  in  number,  ten  in 
each  jaw.  Prom  the  front  backward  we  have  in  each  side 
of  the  jaw  two  incisors,  one  canine  and  two  molars.  The 
first  tooth  to  erupt  is  the  lower  central  incisor  about  the  sixth 
month.  This  set  is  complete  about  the  thirtieth  month. 
About  the  sixth  year  the  jaw  has  enlarged  considerably;  as 
a  result  there  is  room  for  another  tooth  and  the  first  per- 
manent tooth,  the  six-year  molar,  erupts.  Then  the  incisors 
are  erupted,  pushing  out  in  front  of  them  the  temporary 
teeth.  The  last  permanent  tooth  to  erupt  is  the  third  molar 
or  wisdom  tooth,  about  the  twenty-fii*st  year. 

There  are  thirty-two  permanent  teeth,  sixteen  in  each  jaw. 
From  the  front  backward  in  each  side  of  the  jaw  we  have 
two  incisors,  one  canine,  two  bicuspids  and  three  molars. 
The  incisors  cut  the  food,  the  canines  tear  it  and  the  molars 
grind  it. 


272  •  PHYSIOLOGY. 

Through  what  medium  is  the  blood  relieved  of  effete 
matter  and  provided  with  new  material? 

The  blood  is  relieved  of  effete  materials  through  the  sweat, 
urine,  feces  and  exchange  of  respiratory  gases  in  the  lungs. 

It  is  provided  with  new  material  through  the  respiratory 
exchange  of  gases,  from  the  gastrointestinal  tract  through 
the  portal  vein  and  lacteals,  and  from  the  ductless  glands,  as 
the  thyroid,  spleen,  adrenals ;  also  from  marrow  of  bones. 

How  is  normal  body  temperature  regulated  and  sus= 
tained? 

It  is  regulated  by  the  thermotaxic  centers  of  the  nervous 
system,  and  sustained  by  metabolism  of  the  tissues,  especially 
the  muscular  and  glandular. 

State  where  in  the  human  economy  the  following  sub= 
stances  are  found:  fibrin,  chondrin,  leucin,  hippuric  acid. 

Fibrin  is  found  in  clotted  blood,  chondrin  in  cartilage, 
leucin  in  the  intestines,  hippuric  acid  in  urine. 

What  stimuli  produce  muscular  contraction?  What  is 
the  nervous  mechanism  of  muscular  contraction?  IIIus= 
trate. 

Stimuli  producing  muscular  contraction  are  the  normal  ner- 
vous stimulus,  electrical,  mechanical,  chemical,  and  thermal. 

In  the  nervous  mechanism  of  muscular  contraction,  the 
motor  impulse  starts  from  the  motor  nerve  cell,  passing  down 
the  motor  neuraxon  to  the  motor  end  plates,  and  here  the 
muscle  cells  are  stimulated  to  contract.  One  stimulus  would 
simply  eause  a  muscular  twitch,  but  normally  in  a  muscular 
act  a  series  of  impulses  are  sent  from  the  nerve  centers  to 
keep  the  muscles  in  a  voluntary  tetanus. 

In  raising  the  foot  the  motor  impulse  starts  in  the  cere- 
bral grey  cells  of  the  Rolandic  area,  passes  down  to  the  cells  in 
the  anterior  horn  of  the  opposite  side  of  the  lumbar  cord,  then 
out  through  the  sciatic  nerve  to  the  motor  end  plates  of  the 
muscles  required  to  lift  the  foot,  which  in  turn  stimulate 
the  muscular  fibers. 


PHYSIOLOGY.  273 

Define  stammering  and  state  what  causes  it. 

Stammering  is  a  defect  of  speech  due  to  the  spasmodic 
action  of  the  diaphragm  interrupting  the  flow  of  air  past  the 
vocal  cords.     The  larynx  and  lips  are  under  control. 

Define  and  describe  respiratory  rhythm,  respiratory 
sounds. 

Respiratory  rhythm  is  the  relation  between  the  time  of  in- 
spiration and  expiration.  Inspiration  is  to  expiration  as  five 
is  to  six,  the  expiration  being  followed  by  a  short  pause. 

The  respiratory  sounds  are  the  sounds  heard  in  auscultating 
the  lungs.  There  are  two  sounds.  One  is  the  vesicular  breath- 
ing, which  is  a  low-pitched,  soft,  distant  breezy  sound,  the  in- 
spiration being  to  expiration  as  three  or  four  is  to  one,  in  fact 
■expiration  may  be  a  mere  puff. 

The  second  is  the  bronchial  breathing,  heard  over  the 
trachea  and  primary  bronchi.  It  is  high-pitched,  blowing  or 
tubular  in  quality,  the  expiration  being  louder,  a  little  longer 
and  higher  pitched  than  inspiration. 

What  are  the  functions  of  the  skin  and  its  appendages? 

The  skin  and  its  appendages  protect  from  drying  and 
other  injury  the  underlying  tissues,  especially  the  end  or- 
gans of  the  sensory  nerves  in  the  skin.  The  hair  prevents 
friction  and  also  protects  sensitive  parts  from  extremes  of 
temperature.  On  account  of  the  large  extent  of  its  surface 
and  also  on  account  of  the  sweat  glands  it  contains,  the  skin 
is  a  great  heat-dissipating  organ. 

Define  myopia,  hypermetropia,  astigmatism.  State  the 
cause  of  each  of  these  conditions. 

Myopia  or  nearsightedness  is  a  defect  in  vision  in  which 
parallel  rays  of  light  are  focussed  in  front  of  the  retina.  It 
is  due  usually  to  an  increased  length  in  the  anteroposterior 
diameter  of  the  eye. 

Hypermetropia  or  farsightedness  is  a  defect  in  vision  in 
which  parallel  rays  of  light  are  brought  to  a  focus  beyond 
18 


274  PHYSIOLOGY. 

the  retina.     It  is  generally  due  to  a  shortening  of  the  an- 
teroposterior diameter  of  the  eye. 

Astigmatism  is  an  error  of  refraction  in  which  rays  of  light 
in  the  various  planes  are  not  equally  refracted,  some  of  the 
rays  possibly  being  focussed  on  the  retina,  others  behind  or 
in  front  of  it.  It  is  generally  due  to  irregularities  in  the 
curvature  of  the  cornea,  but  sometimes  of  the  lens. 

What  is  the  physiologic  function  of  the  liver? 

The  liver  secretes  bile,  forms  glycogen,  urea,  uric  acid,  con- 
jugate sulphates,  destroys  some  of  the  red  corpuscles  and  in 
fetal  life  forms  some  red  corpuscles.  It  also  destroys  many 
poisons  taken  into  the  body. 

State  the  manner  in  which  blood  circulates  through  the 
heart  and  the  lungs,  beginning  at  the  right  auricle. 

The  blood  passes  from  the  right  auricle  through  the  tri- 
cuspid valve  into  the  right  ventricle;  thence  through  the 
pulmonary  valve  into  the  pulmonary  artery,  which  divides 
and  subdivides,  finally  ending  in  the  capillaries  around  the 
air  cells.  The  blood  is  re-collected  and  emptied  by  the  pul- 
monary veins  into  the  left  auricle;  then  it  passes  on  through 
the  mitral  valve  into  the  left  ventricle;  it  is  then  forced  out 
through  the  aortic  valve  into  the  aorta. 

Compare  arteries,  veins  and  capillaries  in  respect  ta 
rapidity  of  the  blood  stream. 

The  blood  flows  in  the  arteries  at  about  the  rate  of  twelve 
inches  a  second,  in  the  veins  seven  inches  a  second,  and  in  the 
capillaries  two  inches  a  minute. 

Name  the  excretory  glands  of  the  body  and  the  function 
of  each. 

The  excretory  glands  are  the  kidneys,  which  excrete  urine; 
the  sweat  glands,  which  excrete  sweat  and  dissipate  heat  by 
sweating;  and  the  liver,  which  throws  off  through  the  bile 
some  waste  matter.  The  lungs  are  also  excretory  organs,, 
throwing  off  carbon  dioxide  and  nitrogen. 


PHYSIOLOGY.  275 

Describe  the  origin  of  a  tear  as  the  result  of  pain. 

The  pain  causes  reflexly  a  stimulation  of  the  lachiymal 
gland,  causing  an  increased  secretion.  More  secretion  is 
poured  out  than  can  be  carried  off  by  the  lachrymal  canal, 
the  excess  pouring  over  the  cheek  as  tears. 

What  is  the  office  of  the  columnae  carneae? 

They  give  strength  to  the  ventricular  wall  and  prevent 
the  auriculo-ventricular  valves  from  being  pressed  into  the 
auricles. 

Describe  the  physiologic  causes  of  obesity. 

The  physiological  causes  of  obesity  are  overfeeding,  espec- 
ially with  carbohydrates,  lack  of  proper  exercise,  and  cer- 
tain peculiarities  of  the  cells  of  an  individual. 

Name  some  of  the  bodily  states  which  lessen  the  alka= 
linity  of  the  blood. 

There  is  a  decrease  of  alkalinity  in  rheumatism,  gout,  mi- 
graine, and  while  living  on  a  diet  deficient  in  the  alkaline 
mineral  matters,  or  living  on  a  proteid  diet. 

What  is  the  influence  of  diet  on  nutrition? 

For  nutrition  to  go  on  properly  the  diet  must  contain  the 
various  classes  of  foods  in  proper  proportion.  Proteids  and 
salts  are  absolutely  necessary.  Nothing  but  proteids  can 
replace  the  used-up  proteids  of  tissue.  Salts  are  needed 
especially  to  neutralize  the  acids  formed  during  proteid  kata- 
bolism,  and  to  form  a  part  in  the  secretions,  like  the  hydro- 
chloric acid  of  the  gastric  juice. 

Describe  the  physiologic  process  by  which  the  bite  of  a 
venomous  snake  or  the  hypodermic  injection  of  the  virus 
causes  death. 

The  poison  injected  under  the  skin  is  carried  by  the  lym- 
phatics to  the  right  or  left  subclavian  vein.  Having  thus 
reached  the  general  circulation,  it  is  distributed  to  the  various 
organs,  and  so  perverts  the  function  of  certain  ones  as  to 
cause  death. 


276  PHYSIOLOGY. 

Name  the  bile  salts,  and  state  the  physiologic  function 
of  bile. 

The  bile  salts  are  sodium  glyeocholate  and  sodium  tauro- 
cholate. 

Bile  aids  in  the  emulsification  and  absorption  of  fats,  neu- 
tralizes the  acid  chyme,  precipitating  the  pepsin,  increases 
peristalsis,  and  contains  some  waste  matter  thro\vn  off  by  the 
liver. 

Describe  the  offices  and  the  characteristics  of  the  gray 
matter  of  the  brain. 

The  gray  matter  of  the  cerebral  cortex  is  arranged  in  six 
alternate  gray  and  white  layers,  the  most  important  of  which 
is  the  deep  gray  layer  of  large  pyramidal  cells. 

The  gray  matter  of  the  cerebrum  is  the  center  of  sensa- 
tion, volition  and  ideation;  that  is,  it  receives  the  sensations, 
sends  out  all  voluntary  impulses  and  is  the  part  of  the  ner- 
vous system  in  which  thought  goes  on. 

Enumerate  the  physiologic  advantage  of  natural  sleep 
and  state  at  what  period  of  life  the  least  sleep  is  required. 

Natural  sleep  allows  the  fatigued  nervous  system  to  regain 
its  tone,  causes  a  relaxation  of  the  vasomotor  system,  thus 
giving  the  heart  a  chance  to  rest.  In  fact,  sleep  causes  a  re- 
laxation of  all  the  bodily  functions,  thus  allowing  the  tissue 
to  recuperate  and  waste  matter  to  be  carried  off. 

During  mature  adult  life  the  body  can  stand  the  lack  of 
sleep  better  than  at  any  other  time. 

What  part  of  the  retina  is  most  sensitive  to  visual  sen= 
sations?     Explain. 

The  fovea  centralis  within  the  yellow  spot  of  Soemmering. 
It  contains  the  layer  of  cones  which  are  concerned  in  acute 
vision. 

Mention  the  special  end  organs  of  the  sense  at  taste  and 
state  where  each  type  is  found. 

Taste  bulbs.    For  acids  and  sweets,  the  anterior  two-thirds 


PHYSIOLOGY.  277 

of  the  tongue.     For  saline  and  bitter,  the  posterior  one-third 
of  the  tongue. 

Give  the  physiologic  explanation  of  the  rapid  respiration 
of  pneumonitis. 

Pneumonitis  rendering  a  greater  or  lesser  portion  of  the 
lung  functionless  interferes  with  the  exchange  of  gases  in 
the  lungs.  The  resulting  excess  of  CO,  in  the  blood  stimulates 
the  respiratory  center  to  greater  activity. 

Describe  the  course  of  a  motor  impulse  from  its  source 
in  the  cerebral  cortex  to  the  calf  of  the  leg. 

The  impulses  originate  in  the  motor  cells  of  the  ascending 
frontal  convolution  (superior  portion),  pass  down  through 
the  anterior  part  of  the  posterior  segment  of  the  internal 
capsule,  through  the  pes  of  the  crura  cerebri,  the  pons,  to 
the  pyramids  of  the  medulla  where  three-fourths  of  the  fibres 
decussate  to  form  the  Crossed  Pyramidal  tract  of  the  cord. 
The  other  one-fourth  forms  the  Direct  Pyramidal  tract  cross- 
ing in  different  levels  of  the  corl.  Both  tracts  end  about 
the  motor  cells  in  anterior  horns  of  the  lower  lumbar  cord. 
Prom  these  cells  new  axones  arise,  emerge  by  the  anterior 
roots,  and  per  the  sacral  plexus  and  sciatic  nerve  and  its 
branches  to  the  calf  of  the  leg. 

Give  localization  in  the  cerebral  cortex  of  the  motor 
function  of  (a)  the  left  side  of  the  face,  (b)  the  right  arm, 
(c)  the  left  leg. 

(a)  Inferior  part  of  right  ascending  frontal  convolution. 
(b)  Middle  part  of  left  ascending  frontal  convolution,  (c) 
Superior  part  of  right  ascending  frontal  and  paracentral  con- 
volutions. 

.^Describe  the  mechanism  by  which  the  voice  is  produced. 

A  blast  of  air  developed  by  the  lungs  and  thorax  strikes 
the  vocal  cords,  which  are  properly  approximated,  produces 
sounds.    These  are  modified  by  the  nose,  mouth  and  pharynx. 


278  PHYSIOLOGY. 

Explain  the  function  of  the  foramen  ovale  of  the  fetal 
heart. 

The  foramen  ovale  permits  most  of  the  venous  blood  in 
the  right  auricle  to  pass  into  the  left  auricle  instead  of  pass- 
ing through  the  right  ventricle  and  on  to  the  non-functioning 
lung. 

How  is  the  cornea  nourished? 

By  lymphatics  which  drain  into  the  Canal  of  Schlemm. 

Describe  the  normal  muscular  movements  of  the 
stomach  and  state  the  physiologic  purpose  of  each  type 
of  movement. 

There  are  two  principal  movements  of  the  stomach.  A  con- 
striction wave  beginning  in  the  fundus  and  passing  on  to  the 
pylorus,  pressing  the  foods  on  through  the  pylorus.  If  masses 
too  large  to  pass  the  pylorus  are  present  a  reverse  wave  is 
set  up  pressing  the  food  masses  toward  the  fundus  again. 
The  process  is  again  repeated  until  all  food  masses  are  re- 
duced. These  constriction  waves  have  three  functions — trit- 
uration, mixing  and  expulsion. 

Explain  the  importance  of  thorough  mastication  as  re= 
lated  to  digestion. 

Thorough  mastication  is  essential,  the  finely-divided  foods 
being  more  readily  acted  upon  by  the  digestive  ferments. 
The  food  is  more  thoroughly  insalivated.  It  also  reflexly 
stimulates  the  flow  of  the  digestive  fluids. 

Describe  the  physiologic  phenomena  of  lactation. 

Lactation  is  the  secretion  of  milk  for  the  nourishment  of 
the  offspring.  Colostrum,  the  first  secretion,  is  followed  in 
3  to  5  days  by  the  true  milk.  This  secretion  is  stimulated  by 
a  hormone  liberated  by  the  fetus.  Lactation  also  stimulates 
the  involution  of  the  uterus  reflexly. 

Describe  the  physiologic  function  of  the  Organ  of 
Corti. 

The  Organ  of  Corti  contains  the  Arches  of  Corti  and  the 


PHYSIOLOGY.  279 

auditory  cells  resting  on  the  Cords  of  Neul  of  the  basilar 
membrane,  the  hair-like  processes  of  the  cells  pierce  the  retic- 
ular membrane  and  are  attached  to  the  Membrane  of  Corti. 
The  vibrations  of  the  endolymph  in  the  cochlear  canals  are 
taken  up  by  the  Cords  of  Neul  shaking  the  auditory  cells  and 
stimulating  the  terminals  of  the  cochlear  part  of  the  auditory 
nerve.  These  impressions  are  carried  to  the  temporal  con- 
volutions and  there  interpreted.  The  Reticular  and  Corti 
Membranes  act  as  dampers  preventing  excessive  vibrations. 

What  physiologic  processes  are  involved  in  the  manifes= 
tation  of  a  fever? 

Fever  is  due  to  an  irritant,  traumatic  or  a  toxin  of  in- 
fectious or  metabolic  origin,  stimulating  the  thermogenic  cen- 
ters. Heat  production  greatly  exceeds  heat  dissipation  in  the 
early  part  of  the  fever,  later  the  fever  is  the  result  of  a  dis- 
arrangement of  the  thermotaxic  mechanism.  The  wasted 
tissues  in  the  later  stages  could  hardly  keep  up  the  continued 
fever;  e.  g.,  typhoid  or  malaria,  biliousness,  or  injuries,  par- 
ticularly to  head. 

What  important  functions  of  the  body  are  dependent  on 
the  presence  of  NaCI  in  the  body?  Describe  the  prepara= 
tion  of  normal  salt  solution. 

Half  of  the  osmotic  pressure  of  the  body  is  dependent  on 
NaCl.  It  determines  the  amount  of  water  in  the  tissues.  Ab- 
sorption and  secretion  are  dependent  on  it.  With  K  and  Ca 
it  maintains  the  activity  of  the  contractile  tissues.  Normal 
salt  solution  is  0.95%  NaCl  in  water. 

Describe  the  corpus  luteum  and  explain  its  relation  to 
menstruation  and  to  pregnancy. 

The  corpus  luteum  is  the  yellowish  opaque  body  filling  the 
«pace  in  the  ovary  formed  by  the  bursting  of  the  Graafian 
follicle  to  liberate  the  ovum.  It  contains  lutein.  The  true 
corpus  luteum,  of  pregnancy,  is  larger,  thicker  and  deeper 
in  color  than  the  false  corpus  luteum  of  menstruation. 


280  PHYSIOLOGY. 

Describe  the  costal  and  the  abdominal  type  of  breathing. 
State  cause  of  each. 

The  costal  type  of  breathing  is  manifested  by  the  expansion 
of  the  thorax  in  inspiration.  It  is  caused  by  the  rotation  of 
the  ribs  upward  and  outward  by  the  thoracic  muscles.  Seen 
commonly  in  women.  Constricting  bands  about  the  abdomen 
conduce  to  this  type. 

The  abdominal  type  is  manifested  by  expansion  of  the  ab- 
domen in  inspiration.  It  is  caused  by  the  contracting  dia- 
phragm pushing  the  abdominal  viscera  downward,  expanding 
the  abdomen.    Seen  commonly  in  males. 

Explain  in  detail  the  function  of  the  kidney. 

The  kidney  secretes  the  urine.  Its  parenchyma  is  com- 
posed of  (a)  cortex — ^containing  the  glomeruli,  which  excrete 
the  water  and  salts;  (b)  medulla. — containing  the  convoluted 
tubules  which  excrete  the  urea  and  organic  constituents. 

Describe  the  results  of  a  disturbance  of  the  glycogenic 
function  of  the  liver. 

In  disturbances  of  the  glycogenic  function  of  the  liver,  the 
glucoses  instead  of  being  stored  in  the  liver  as  glycogen  pass 
to  the  general  circulation  and  are  excreted  in  the  urine  by  the 
kidneys,  producing  a  form  of  diabetes. 

Explain  endogenous  (internal)  and  exogenous  (external) 
sources  of  purin  bases  and  the  production  of  uric  acid. 

The  purin  bases  are  adenin,  guanin,  xanthin  and  hypo- 
xanthin. 

They  are  derived  from  the  nucleins  obtained  from  the  meta- 
bolism of  the  nuclei  of  the  tissues  (endogenous).  Also  de- 
rived from  the  nuclei  of  the  foods  (exogenous).  These  purins 
acted  on  by  xanthinoxidase  produce  uric  acid.  Ham,  veal 
and  malt  or  fermented  liquors  contain  large  quajitities  of 
nuclein. 


PATHOLOGY  AND  BACTERIOLOGY. 


Describe  the  protective  agencies  by  which  the  body 
guards  itself  against  the  entrance  and  harmful  effects  of 
pathogenic  bacteria. 

Phagocytosis,  the  ingestion  and  possible  destruction  of  bac- 
teria by  certain  leukocytes.  Antitoxins,  substances  formed 
in  the  body  that  are  antidotal  to  bacterial  toxins.  Bacterio- 
lysins,  substances  resulting  from  the  union  of  two  bodies 
known  as  complement  and  addiment  that  produce  the  solution 
of  bacteria.  Antiseptic  substances  present  in  the  blood  serum 
and  tissues  that  restrain  bacterial  growth. 

What  is  immunity?     How  is  immunity  produced? 

Immunity  expresses  the  degree  of  resistance  of  the  living 
organism  against  disease.  It  is  produced  by  attacks  of  dis- 
ease, by  the  introduction  into  the  body  of  living  or  dead  bac- 
teria or  their  products,  or  of  antitoxins  or  by  heredity. 

Give  the  pathologic  changes  occurring  in  acute  phlebitis. 

Congestion  of  vessels  of  vasa  vasorum  and  effusion  in  The 
walls  of  vein  of  serum  and  leukocytes,  with  formation  of 
thrombus  within  vessel.  This  may  terminate  in  absorption 
and  resolution,  the  permanent  occlusion  of  the  vein,  or  in  sup- 
puration. 

What  conditions  (non-traumatic)  favor  cerebral  hemor- 
rhage? Mention  the  vessel  from  which  cerebral  hemor- 
rhage occurs  most  frequently. 

a.  Arterio-sclerosis  or  aneurysm  of  cerebral  vessels  and 
their  causes,  cerebral  tumor,  infarction,  whooping  cough  or 
convulsions,  leukemia,  pernicious  anemia. 

b.  The  left  lenticulo-striate  artery. 

(281) 


282  PATHOLOGY  AND  BACTERIOLOGY. 

Give  the  histologic  characteristics  of  amyloid  degen= 
eration. 

The  amyloid  substance  appears  in  the  form  of  irregular 
homogeneous,  translucent,  faintly  granular  areas  of  fused 
cells  and  intercellular  substances  affecting  chiefly  the  con- 
nective tissues  about  the  capillaries,  as  in  the  glomeruli  of 
kidnej^  or  spleen.  The  adjacent  epithelial  cells  may  show 
atrophic  changes  or  fatty  degeneration.  The  urinary  tubules 
may  contain  amyloid  casts. 

What  are  the  blood  changes  in  progressive  pernicious 
anemic? 

A  marked  and  disproportionate  oligocythemia,  slight  leu- 
copenia,  poikilocytosis,  and  the  presence  of  nucleated  red 
corpuscles. 

Give  the  gross  and  the  microscopic  appearance  of  an 
epithelioma  of  the  lip. 

A  crushed  papule  or  warty  growth,  with  infiltrated  base, 
that  tends  to  undergo  crater-like  ulceration.  Microscopically, 
an  invasion  of  the  subcutaneous  and  deeper  tissues  by  irreg- 
ular columns  composed  of  squamous  epithelial  cells  that  often 
contain  pearly  bodies. 

Give  the  function  and  the  products  of  bacteria. 

Functions  are  reproduction,  motion,  absorption,  excretion, 
growth ;  also  fermentation,  decomposition,  disease-production. 
They  may  produce  ferments,  toxins,  phosphorescence,  pig- 
ments, acids  or  alkalies. 

Give  the  causes  of  edema. 

Passive  hyperemia,  anemia,  change  in  vessel  walls  or  in 
vascular  innervation,  reduction  in  extra-vascular  pressure, 
lymphatic  obstruction. 

What  are  cysts?  How  are  cysts  formed?  Give  the 
varieties  of  cysts. 

Abnormal,  persistent,  encapsulated  collections  of  liquid 
formed  by  obstruction  to  outlet  of  glands,  by  secretion  in  a 


PATHOLOGY  AND  BACTERIOLOGY.  283 

cavity  without  outlet,  extravasation  of  blood  or  other  liquid, 
softening  of  tissues,  tumor  formation,  or  by  the  presence  of  a 
parasite  or  foreign  body.  Varieties  are  simple,  compound, 
and  proliferous,  congenital,  retention,  extravasation,  soften- 
ing, neoplastic  and  parasitic  cysts. 

What  is  the  special  cause  of  the  croupous  inflammation 
found  in  diphtheria? 

The  toxin  of  the  diphtheria  bacillus. 

Describe  the  comma  bacillus  and  give  the  manner  of  its 
introduction   into  the   system. 

A  spirillum,  a  short,  curved  rod  .8  to  2  microns  in  length, 
motile,  flagellate,  readily  staining  but  decolorized  by  Gram's 
method,  usually  enters  through  the  alimentary  canal  with 
contaminated  water,  milk  or  solid  food. 

What  conditions  give  to  the  system  immunity  from  the 
harmful  action  of  bacteria? 

The  baeteriolysins,  the  antitoxins,  the  phagocytes,  the  anti- 
septic action  of  tissue  cells  and  juices,  the  protecting  layers 
of  epithelium. 

(a)  Give  the  microscopic  appearance  of  a  melano=sar= 
coma  and  (b)  state  its  usual  sites  of  development. 

(a)  Consists  usually  of  vascularized  tissue  consisting  of 
spindle  cells,  or  at  times  of  round  cells,  that  have  vesicular 
nuclei,  and  many  of  which  contain  dark  pigment  granules, 
(b)   Skin  and  choroid. 

Describe  the  pathologic  conditions  in  meningitis. 

An  inflammation  of  the  membranes  of  brain  or  cord  char- 
acterized by  congestion  of  meningeal  vessels,  edema  of  arach- 
noid, effusion  of  serum,  fibrin,  or  pus  into  the  cavity  of  arach- 
noid, at  times  petechial  or  larger  hemorrhages  within  or  with- 
out arachnoid.  Adjacent  degeneration  of  nervous  substance 
may  occur. 

Give  the  pathology  of  cirrhosis  of  the  liver. 

A  markefl  hyperplasia  of  the  interlobular  connective  tissue. 


284  PATHOLOGY  AND  BACTERIOLOGY. 

and  often  of  interlobular  bile  ducts.  The  new-formed  con-^ 
nective  tissue  tends  to  contract,  compressing  the  lobules  and 
perhaps  causing  degeneration  of  the  hepatic  cells.  The  liver 
may  become  much  smaller  and  show  a  rough  ("  hob  nail  ") 
surface. 

(a)  How  is  fibrous  tissue  formed?  (b)  What  tumors 
are  composed  largely  of  fibrous  tissue,  and  in  what  part  of 
the  body  do  they  usually  occur? 

(a)  By  a  proliferation  of  cells  of  the  pre-existing,  adjacent 
fibrous  tissue.  The  young  cells  or  fibroblasts  being  nourished 
by  new  capillary  blood-vessels  that  sprout  from  neighboring 
pre-existing  vessels  and  invade  the  formative  area. 

(b)  Fibromas  and  fibromyomas  chiefly  occur  in  the  uterus. 

What  is  the  significance  of  tube=casts  in  the  urine? 

Tube-casts  result  from  irritative  and  degenerative  changes, 
in  the  epithelium  of  kidney,  permitting  an  exudation  of  coag- 
ulable  substance  into  the  tubules,  and  signify  renal  irritation 
or  disease.  They  are  minute  cylindric  bodies  having  a  homo- 
genie  matrix,  in  which  there  may  be  imbedded  cellular  or 
granular  particles. 

Describe  yellow  or  crude  tubercle. 

A  yellowish,  rounded,  firm,  adherent  body,  one  to  several 
millimeters  in  diameter,  showing  under  microscope  a  central 
caseous  area,  an  intermediate  zone  of  epithelioid  cells  and 
often  giant  cells,  and  a  peripheral  zone  of  lymphocytes. 

Give  the  structural  differences  between  sarcoma  and 
carcinoma. 

Sarcoma  consists  of  connective  tissue  of  embryonic  type 
containing  imperfectly  formed  blood-vessels.  Tissue  may 
consist  of  round,  oval,  spindle  or,  in  part,  of  giant  cells. 

Carcinoma  is  less  circumscribed,  consists  of  alveoli  filled  by 
cuboidal,  columnar  or  squamous  epithelial  cells  in  a  stroma, 
usually  of  fibro-connective  tissue,  that  contains  well-formed" 
blood-vessels  and  lymphatics. 


PATHOLOGY  AND  BACTERIOLOGY.  285 

Define  anemia,  hyperemia,  leukemia. 

Anemia  is  deficiency  in  the  quantity  or  quality  of  circulat- 
ing blood. 

Hyperemia  is  an  excessive  quantity  of  circulating  blood  in 
a  part. 

Leukemia  is  a  grave  primary  anemia  characterized  by  enor- 
mous leucocytosis  and  pathologic  changes  in  the  spleen,  red 
marrow  or  lymphatics. 

State  the  difference  between  degeneration  and  infiltra= 
tion.     Illustrate. 

Cell  degeneration  is  a  condition  in  which  the  cell  contents 
become  abnormal.  If  abnormal  from  the  deposit  of  substance 
from  without  it  is  termed  cell  infiltration,  as  in  fatty  infiltra- 
tion. If  abnormal  from  transformation  of  cell  contents  it  is 
termed  a  cell  metamorphosis,  as  in  fatty  metamorphosis. 
Fatty  infiltration  anl  fatty  metamorphosis  are  both  examples 
of  cell  degeneration. 

Give  the  morbid  anatomy  of  chronic  bronchitis. 

Mucous  membrane  may  be  red  and  thickened  and  covered 
by  thick  mucus;  or  pale,  thinned,  and  showing  adherent,  in- 
spissated mucous  masses.  The  thickening  is  due  to  leueo- 
•cytic  infiltration  and  overgrowth  of  fibrous  tissue;  the  thin- 
ning to  atrophy  of  the  mucous  membrane.  The  ciliated  cells 
may  be  replaced  by  columnar  or  polygonal  epithelium. 

What  is  thrombosis?  Describe  the  manner  of  its  for- 
mation. 

Thrombosis  is  the  intravascular  coagulation  of  blood  during 
life  resulting  from  the  arrest  of  circulation  and  the  formation 
of  fibrin  by  the  action  of  fibrin  ferment  upon  the  fibrinogen. 

(a)  What  is  mucoid  degeneration?  (b)  What  is  col- 
loid degeneration? 

(a)  A  conversion  of  cells  and  intercellulai-  substances  into 
mucin. 

(b)  A  conversion  of  cells  into  colloid  iiiateiiiil.  a  substancv^ 
resembling  mucin  ])nt  not  giving  its  i-eaction. 


286  PATHOLOGY  AND  BACTERIOLOGY. 

State  the  results  of  stenosis  of  the  tricuspid  valves  of 
the  heart. 

Dilatation  of  right  auricle,  cyanosis  of  face,  passive  hy- 
peremia of  pulmonary  and  abdominal  organs,  anasarca. 

(a)  Define  fatty  metamorphosis,  (b)  Give  its  termin= 
ations. 

(a)  Conversion  of  cells  into  fat. 

(b)  Destruction  of  cells,  eoUiquation  or  caseous  necrosis. 

What  are  the  possible  lesions  in  the  third  stage  of 
syphilis? 

Gummata,  syphilitic  rupia,  sclerotic  changes  in  organs, 
especially  the  arteries,  liver,  kidneys  and  spinal  cord. 

Describe  the  local  appearances  in  a  case  of  embolism  of 
the  middle  meningeal  artery. 

The  affected  vessel  contains  thrombus  extending  from  the 
seat  of  embolism  back  as  far  as  the  first  collateral  branch. 
The  distal  branches  may  be  shrunken,  anemic,  and  associated 
with  cerebral  softening  or  distended,  and  in  the  midst  of  a 
hemorrhage  effusion  (hemorrhagic  infarction). 

What  is  productive  inflammation? 

Inflammation  characterized  by  the  formation  of  new  tissue, 
usually  of  the  fibro-connective  type. 

What  changes  take  place  in  hypertrophy  of  the  heart? 

An  increase  in  thickness  of  the  muscular  walls  of  the  heart, 
chiefly  affecting  the  ventricle,  blunting  the  apex.  The  cavi- 
ties may  or  may  not  be  increased  in  size. 

Give  the  origin  and  appearance  of  papillomata. 

Originate  from  overgrowth  of  the  papillary  body,  and  are 
wart-like,  villous,  dendritic  or  polypoid  outgrowths  from  skin 
or  mucous  membrane  covered  by  epithelium. 

Briefly  describe  the  types  of  gangrene,  and  give  the 
conditions  determining  each. 

Dry  gangrene  or  putrefactive  death  of  a  part  with  mummi- 


PATHOLOGY  AND  BACTEBIOLOGY.  287 

tication  is  characterized  by  a  dry,  shriveled,  blackish,  leathery, 
friable  area,  and  is  caused  by  arterial  obstruction,  such  as 
occurs  in  old  age  (senile  gangrene),  from  arterio-sclerosis,  in 
Raynaud's  disease,  from  ergot  poisoning  and  frostbite. 

Moist  gangrene  is  characterized  by  swollen,  greenish  or 
blackish,  cool,  moist,  soft,  fetid  area,  with  bleb-covered  sur- 
face, loosened  epidermis  and  crepitation  on  palpation,  and  is 
due  to  severe  infection  (pulmonary  gangrene,  malignant  pha- 
gedena, hospital  gangrene),  trauma,  venous  obstruction,  dia- 
betes (diabetic  gangrene),  and  deficient  trophic  innervation 
(decubitus). 

Describe  the  histological  elements  of  carcinoma. 

Acini  containing  epithelial  cells.  The  amount  of  proto- 
plasm, as  in  other  epithelial  cells,  is  large  in  proportion  ta 
the  size  of  the  nucleus.  Cells  may  be  squamous  cylindric, 
cuboidal  or  polyhedral.  The  nuclei  are  usually  atypical  kar- 
yokinetic,  and  other  cell  figures  may  be  present.  The  stroma 
usually  consists  of  well-formed  fibro-connective  tissue  con- 
taining lymphatics  and  wi^ll-foi-nied  blood-vessels. 

Describe  tuberculosis  of  the  skin  in  any  of  its  forms. 

Lupus  vulgaris  is  characterized  by  brown  nodules  originat- 
ing in  corium,  and  consisting  of  a  rather  vascular  granula- 
tion tissue  composed  of  epithelioid  cells,  lymphoid  cells,  and 
frequently  of  giant  cells.  The  nodules  may  lead  to  extensive 
ulceration  and  cicatrization. 

Describe  the  changes  in  the  heart  due  to  fatty  meta= 
morphosis. 

Diffuse  or  circumscribed,  yellowish,  opaque,  .soft,  friable 
areas  of  heart  muscle;  in  the  circumscribed  form  chiefly  occur- 
ring under  endocardium  of  papillary  muscles.  Microscopic- 
ally, the  muscle  fibres  lose  their  striation  and  show  fatty 
irranules.  usually  first  about  the  nuclei ;  finally,  fibres  may 
hroak  down  into  fatty  particles  and  detritus. 


288  PATHOLOGY  AND  BACTERIOLOGY. 

What  histological  changes  occur  in  acute  simple  inflam- 
mation? 

Dilatation  of  blood-vessels,  retardation  and  stasis  of  blood 
current,  exudation  into  tissues  of  modified  plasma,  transmi- 
gration of  leukocytes,  and  often  diapedesis  of  erythrocytes, 
distension  of  lymphatics  by  exudate  of  cells  and  fluid,  regen- 
erative or  degenerative  changes  in  the  tissue  cells. 

Give  the  pathology  of  carcinoma. 

Carcinoma  is  a  malignant,  uncircumscribel  tumor  consist- 
ing of  acini,  containing  invaded  epithelial  cells  in  a  vascular- 
ized stroma  that  usually  consists  of  fibro-connective  tissue. 
The  epithelial  cells  tend  to  a  progressive  invasion  through 
the  lymphatic  channels. 

What  is  fibrinous  degeneration? 

A  retrogressive  process  in  which,  by  the  action  of  fibrin 
ferment  upon  fibrinogen,  fibrin  is  formed. 

What  do  you  understand  by  the  term  cirrhosis  of  the 
liver? 

Overgrowth  in  the  liver  of  connective  tissue  that  contracts, 
rendering  the  organ  smaller  and  firmer. 

Is  cerebro=spinal  fever  more  generally  sporadic  or  en= 
demic? 

Cerebro-spinal  fever  generally  occurs  in  the  form  of  small 
sporadic  epidemics. 

Give  some  of  the  lesions  in  chronic  diffused  or  inter= 
stitial  nephritis. 

Macroscopic.  Small,  granular-surfaced  kidney  with  adher- 
ent capsule  and  thinned  cortex. 

Microscopic.  Thickening  of  Bowman's  capsules,  hyaline 
degeneration  of  glomeruli,  increase  of  intertubular  tissue, 
dilatation  of  certain  tubules. 

What  anatomic  changes  take  place  in  the  skin  in  chronic 
eczema? 

Enlargement   of   papillae,    dilatation    of   blood    and    lymph 


PATHOLOGY  AM)  BACTERIOLOGY.  289 

vessels,  perivascular  cellular  infiltration,  hyperplasia  of  con- 
nective tissue  and  epithelium,  atrophy  of  sebaceous  and  sweat 
glands. 

What  are  the  characteristic  features  of  diphtheritic  ex  = 
udation  or  infiltration  of  mucous  membrane? 

The  layers  of  mucous  membrane  undergo  coagulation  ne- 
crosis, and  are  infiltrated  by  a  granular  or  fibrillar  exudation 
of  fibrin,  and  by  leukocytes. 

What  abnormal  organic  ingredients  are  found  in  the 
urine  in  chronic  morbus  Brightii? 

Tube  ca-sts — hyaline,  granular  or  cellular ;  cylindroids,  epi- 
thelial cells  from  urinary'  tubules,  albumin,  and  at  times  leu- 
kocytes and  erythrocytes. 

In  what  general  respects  do  anemia  and  progressive 
pernicious  anemia  differ? 

Anemia  refers  to  any  blood  impoverishment.  Pernicious 
anemia  is  a  very  serious  type  of  an  essential  anemia  in  which 
there  is  a  disproportionate  oligocythemia.  In  most  anemias 
this  is  proportionate  to  the  oligochromemia. 

What  is  cretinism,  and  with  what  is  it  associated? 

A  disease  developing  in  early  life  characterized  by  disten- 
tion (at  times  myxomatous)  of  subcutaneous  tissues  and  by 
general  mental  and  physical  ill  development,  that  is  always 
associated  with  abnormality  oi-  absence  of  the  thyroid  gland. 

How  should  sputum  be  examined  for  tubercle  bacilli? 

A  selected  portion  of  morning  expectxjration  is  thinly  spread 
on  a  cover-glass,  dried,  fixed  by  heating,  stained  for  three 
minutes  in  hot  carbol-fuchsin.  washed,  decolorized  and  coun- 
ter-stained for  one-half  minute  in  Ciabbet's  solution,  washed, 
dried,  mounted  in  balsam,  and  examined  under  a  one-twelfth 
oil  immei-sion  objective  for  minute  red  rods — the  tubercle 
bacilli. 

19 


290  PATHOLOGY  AND  BACTERIOLOGY. 

What  is  infective  inflammation?  How  does  it  differ 
from   simple  inflammation? 

Infective  inflammation  is  that  form  due  to  the  action  of 
bacteria,  while  simple  inflammation  is  not  due  to  micro- 
organisms. Infective  inflammation  tends  to  spread,  is  more 
severe,  and  is  often  associated  with  marked  constitutional  re- 
action, the  reverse  being  the  case  in  simple  inflammation. 

Give  the  morbid  anatomy  of  acute  lobar  pneumonia. 

In  engorgement  (first  stage)  the  affected  lobe  is  deep  red, 
boggy,  slightly  crepitant,  and  on  section  exudes  bloody  serum ; 
this  passes  into  red  hepatization  (second  stage),  in  which, 
the  affected  lobe  is  dark  red,  solid,  airless,  friable,  with  dry, 
granular  surface  of  section,  while  in  gray  hepatization  (third 
stage)  the  lobe  is  grayish- white,  solid,  friable,  with  moist 
surface  of  section.  Microscopically,  in  the  first  stage,  there 
is  intense  hyperemia,  with  presence  of  serous  liquid  and  red 
and  white  corpuscles  in  alveoli.  In  the  second  stage  the  air 
cells  are  filled  by  red  and  white  corpuscles  entangled  in 
coagulatel  fibrin,  while  in  the  third  stage  the  fibrin,  erythro- 
cytes and  hyperemia  disappear  and  the  alveoli  are  distended 
by  leukocytes  and  granular  detritus.  Resolution  (fourth 
stage)  is  characterized  by  liquefaction  necrosis,  absorption 
and  expulsion  of  exudate. 

Give  the  causes  and  process  of  cerebral  softening. 

The  chief  causes  are  the  obstruction  of  cerebral  arteries  by 
an  embolus,  thrombus  or  arterio-sclerosis.  The  area  thus  ren- 
dered anemic  degenerates  and  undergoes  colliquation  necrosis, 
and  if  pyogenic  bacteria  are  present  an  abscess  may  form. 

Describe  the  rash  and  give  the  morbid  anatomy  of  scar= 
latina. 

Scattered  red  points  on  a  deep  reddish  'base  appear  over 
neck  and  chest  by  the  second  day,  spread  over  the  body,  and 
after  three  or  four  days  gradually  fade,  to  be  followed  by 
desquamation.  There  are  no  specific  lesions,  but  usually 
acute    catarrhal    or    pseudo-membranons    pharyngitis,    acute 


PATHOLOGY  AND  BACTEEIOLOGY.  291 

diffuse  nephritis,  and  often  follicular  tonsillitis,  lympha- 
denitis (at  times  suppurative),  catarrhal  gastro-enteritis,  in- 
terstitial hepatitis,  splenic  enlargement,  and  as  complications, 
purulent  otitis  media,  endocarditis,  pericarditis,  broncho- 
pneumonia. 

What  is  a  giant  cell?    Give  characteristics. 

A  very  large  cell  with,  many  nuclei,  found  in  the  tubercle, 
in  gumma,  in  bone  marrow,  and  in  myeloid  sarcoma.  It  is 
irregular,  and  often  indefinitely  outlined,  with  hyaline  proto- 
plasm and  from  four  to  one  or  two  hundred  nuclei,  that  may 
be  (as  in  tubercle)  arranged  peripherally,  equatorially,  at 
the  poles  or  (as  in  sarcoma)  near  the  center  of  the  cell. 

Describe  the  formation  of  adipose  tissue. 

In  protoplasm  of  connective  tissue  cells,  fat  droplets  that 
tend  to  coalesce  and  displace  the  nucleus  are  deposited. 
Finally  the  nucleus  is  displaced  to  extreme  periphery  of  cell 
and  may  disappear,  while  the  cell  is  transformed  into  a  dis- 
tended sac  filled  by  fat.  If  this  take  place,  in  many  adja- 
cent connective  tissue  cells  adipose  tissue  results. 

What  pathological   changes  occur  in  caries? 

In  caries  (rarefying  ostitis)  there  is  a  solution  of  bone  with 
or  without  the  formation  of  pus.  A  round-celled  infiltration, 
often  with  the  formation  of  granulation  tissue,  occurs  in 
medulla  and  in  Haversian  canals  with  solution  of  soft  and 
hard  structure  of  bone,  the  ended  pits  being  Howship's 
lacuna;. 

How  is  dental  caries  produced? 

Acids  (especially  lactic)  formed  by  bacteria  present  in  the 
saliva  acting  upon  starchy  particles,  progressively  dissolve 
the  mineral  structure  of  the  tooth,  whereupon  saprophytic 
micro-organisms  present  cause  solution  of  the  organic  sub- 
stance of  the  tooth. 

Describe  catarrhal  inflammation. 

An  inflammation  of  a  mucous  surface,  with  the  fluid  exuda- 


292     PATHOLOGY  AND  BACTERIOLOGY. 

tion  consisting"  of  mucus,  serum,  leukocytes  and  desquamated 
epithelial  cells  in  varying  proportions.  The  area  affected  is 
red,  swollen  and  bathed  by  exuded  secretion. 

What  is  the  line  of  demarcation  in  gangrene? 

The  zone  of  inflammatory  reaction  observed  in  the  living 
tissue  adjacent  to  the  gangrenous  area. 

What  is  the  line  of  separation  in  gangrene? 

The  narrow  zone  of  progressive  ulceration  and  molecular 
disintegration  distal  to  the  line  of  demarcation  that  tends  to 
sever  the  connection  between  the  living  and  dead  tissues. 

What  post=morte!Ti  changes  occur  in  the  tissues? 

Rigor  mortis,  algor  mortis,  livores  mortis,  muscular  relaxa- 
tion, formation  of  adipocere,  decomposition. 

Define  atrophy.     Give  the  varieties  of  atrophy. 

The  diminution  in  size  and  functional  capacity  of  a  part. 
It  may  be  simple  or  degenerative,  passive,  active,  senile,  pres- 
sure or  neuropathic  atrophy. 

Differentiate   fatty   infiltration   and   fatty  degeneration. 

In  fatty  infiltration  the  fat  is  from  without  affected  cells, 
and  appears  as  fat  droplets  that  coalesce,  displace  and  obscure 
the  nucleus,  and  distend,  but  do  not  entirely  destroy,  the  cells. 
In  metamorphosis  the  cell  protoplasm  is  converted  into  fat 
that  appears  in  the  form  of  granules  or  minute  droplets  that 
tend  to  cause  the  breaking  down  and  destruction  of  proto- 
plasm and  nucleus. 

Define  fibromata.     Give  the  histology  of  fibromata. 

A  tumor  of  the  type  of  fibro-connective  tissue,  showing 
under  the  microscope  whorls  or  curving  bundles  of  long,  nar- 
row fibers  having  occasional  narrow  spindle-shaped  nuclei. 
As  a  rule,  fibromas  are  encapsulated  and  not  very  vascular. 

Give  the  varieties,  the  histology,  and  the  physical  char= 
acteristics  of  lipomata. 

a.  Diffuse  and  circumscribed,  sessile  or  pediculated. 

b.  Resembles  normal  adipose  tissue,  consisting  of  fat-dis- 


PATHOLOGY  AND  BACTERIOLOGY.  293 

tended  cells  supported  in  a  light  fibro-eonnective  tissue  frame- 
^vork. 

c.  Greasy,  lobulated,  yellowish,  encapsulated,  soft  growths. 
The  overlying  skin  "  dimples  "  when  elevated. 

What  part  of  the  cord  is  involved  in  locomotor  ataxia? 
Give  the  pathology  of  locomotor  ataxia. 

a.  Posterior  columns. 

b.  In  columns  of  Goll  and  Burdach  areas  of  degeneration 
showing  destroyed  myelin  sheaths  and  axis  cylinders  and  a 
proliferation  of  neuroglia  occur. 

What  are  the  intestinal  changes  in  chronic  enteritis? 

The  nuicous  membrane  and  muscular  wall  may  show  hyper- 
plastic thickenings  or  atrophy.  Enlargement  of  lymph  fol- 
licles is  frequent,  and  polypoid  ma.sses  may  project  from 
nuicous  membrane.     Ulcers  may  be  present. 

Define  myomata,  neuromata,  angiomata. 

a.  Myomata  are  tumors  of  the  type  of  muscle. 

b.  Neuromata  are  tumors  of  the  type  of  nerve  tissue. 

c.  Angiomata  are  tumors  of  blood  or  lymph  vessels. 

Explain  the  development  of  pus  corpuscles. 

^Migrating  leukocytes  pass  through  the  walls  of  the  adja- 
cent capillaries,  and  in  large  numbers  invade  the  area  of  sup- 
puration, and  whether  living  or  dead  as  soon  as  they  are  sur- 
I'ounded  by  liquor  puris  are  termed  pus  corpuscles. 

Give  the  pathology  of  spina  bifida. 

The  spinal  lamina  being  congenitally  imperfect,  the  con- 
tents of  the  spinal  canal  tend  to  protrude  in  the  form  of  a 
tumor.  The  mass  usually  contains  fluid,  and  is  covered  by 
the  attenuated  cord,  nerves,  or  by  the  membranes  alone. 
Spina  bifida  occulta  is  a  form  in  which  the  vertebral  cleft  is 
nnassociated  with  the  fonnation  of  a  tumor. 

What  are  the  pathologic  conditions  in  gonorrheal  op- 
thalmia? 

A   piitulcnt  conjunctivitis  witli  marked  chenidsis.  <'dcnia  of 


294     PATHOLOGY  AND  BACTERIOLOGY. 

eyelids,  profuse  purulent  discharge,  and  as  complications, 
ulcerative  or  suppurative  keratitis,  with  or  without  resulting 
perforation,    anterior   synechia,   leucoma,   staphyloma,    iritis, 

iiypopyon. 

What  are  the  pathologic  appearances  of  anemia  of  the 
brain? 

The  blood-vessels  are  empty  or  imperfectly  distended  by 
blood,  and  if  the  process  has  been  long  continued  the  brain 
may  show  atrophy  or  degenerative  changes  in  the  involved 
areas. 

What  is  embolism? 

Intravascular  obstruction  from  the  lodgment  of  a  foreign 
body. 

What  is  an  infarct? 

The  area  of  degenerative  and  inflammatory  changes  pro- 
duced by  the  lodgment  of  an  embolus  in  an  end  artery. 

Describe  the  pathologic  conditions  present  in  atheroma. 

A  diffuse  or  circumscribed  mesarteritis  occurs  with  involve- 
ment of  vasa-vasorum  and  the  production  of  new  sclerotic 
tissue  that  undergoes  coagulation  necrosis  and  fatty  degener- 
ation. This  softened  degenerative  material  is  termed  athero- 
matous. It  may  become  calcified,  be  discharged  with  the 
formation  of  an  atheromatous  ulcer  or  cause  a  weakening  of 
the  wall,  favoring  rupture  or  aneurysm  formation. 

What  structural  changes  take  place  in  chronic  gout? 

Polyarthritis,  with  deposits  of  urate  of  sodium  in  articular 
cartilages,  and  about  joints  with  formation  of  concretions 
(tophi).  Arterio-sclerosis,  hypertrophy  of  left  ventricle  and 
sclerotic  changes  in  liver  and  kidneys  are  common,  and  there 
is  a  tendency  to  inflammation  of  the  larger  serous  sacs. 

What  are  the  four  cardinal  indications  in  inflammation? 

Heat,  swelling,  redness  and  pain,  to  which  may  be  added 
altered  function. 


PATHOLOGY  AND  BACTERIOLOGY.  295 

Define  ascites. 

An  abnormal  collection  of  serous  fluid  in  the  peritoneal 
•cavity. 

What  condition  of  the  blood  is  generally  prominent  in 
ail  forms  of  gout? 

Excess  of  sodium  urate. 

Give  some  of  the  causes  (pathologic)  of  paresis. 

A  chronic,  progressive  meningo-encephalitis  characterized 
"by  a  productive  arteritis  involving  especially  the  adventitia, 
with  degenerative  atrophy  and  sclerosis  of  cortex  and  sub- 
■cortical  portions  of  brain.  Degenerative  changes  in  spinal 
cord  are  associated. 

What  is  the  pathology  of  aneurysm? 

A  localized  enlargement  of  an  artery  containing  blood  or 
<5lot,  due  to  a  circumscribed  stretching  of  one  or  all  the  coats 
of  a  vessel.  It  occurs  in  vessels  weakened  by  trauma,  arterio- 
sclerosis, mycotic  inflammation,  or  by  ulceration,  or  proximal 
to  areas  of  thrombosis  or  embolism.  The  vessel  walls  forming 
the  aneurysm  are  thinned,  often  calcified,  with  impaired  elas- 
ticity, and  usually  having  thicker  or  thinner  lining  of  ad- 
herent, laminated  fibrin. 

Describe  the  pathological  conditions  in  icterus. 

The  skin,  coujuctiva;,  urine,  blood  and  the  various  organs 
*re  tinged  a  yellow  color  by  the  biliary  pigment.  The  feces 
-are  usually  clay-colored.  The  pulse  is  slow;  there  is  a  ten- 
•dency  to  henioi-rhajje. 

Define  the  term  malignant  as  applied  to  new  formations. 

New  growth  having  an  inherent  tendency  to  a  fatal  issue. 

Give   the  pathology  of  peritonitis. 

The  peritoneum  is  red  from  vascular  injection,  the  surface 
is  dull,  and  may  be  covered  by  adherent  fibrinous  or  puriform 
exudate.  The  cavity  of  the  peritoneum  contains  serum,  in 
which  there  may  be  fibrin  or  pus.  There  is  a  tendency  for 
.adjacent  peritoneal  surfaces  to  adhere,  localizing  the  process. 


296     PATHOLOGY  AND  BACTERIOLOGY. 

What  is  understood  by  the  phrase  "  new  formation  "? 

A  multiplication  of  certain  cells  of  the  body  producing  a 
mass  of  tissue  that  has  no  place  in  the  normal  organism,  such, 
for  example,  as  a  tumor. 

By  examining  the  fluid  removed  by  lumbar  puncture, 
how  may  we  distinguish  between  tubercular  and  other 
forms  of  meningitis? 

In  tuberculous  meningitis  the  tluid  contains  chiefly  lympho- 
cytes, and  by  staining,  or  inoculation  into  animals,  the  pres- 
ence of  the  tubercle  bacillus  may  be  demonstrated.  In  other 
forms  of  meningitis  the  cerebro-spinal  fluid,  as  a  rule,  is  more 
turbid,  contains  chiefly  polymorpho-nuclear  leukocytes,  and 
the  causal  organism,  as  the  pneumococcus,  the  diplococcus 
intracellularis  meningitis  or  other  bacterium,  but  not  the- 
tubercle  bacillus. 

Differentiate  a  tuberculous  joint  from  one  enlarged  by 
chronic  rheumatism. 

Tuberculous  joint-disease  occurs  chiefly  in  children,  atfects, 
usually  but  a  single  .joint,  has  insidious  onset,  with  slight  and 
often  characteristically  reflected  pain,  and  muscular  rigidity; 
is  persistent,  and  tends  to  cause  flexion  and  pale,  doughy 
thickening  of  .joint,  with  later  the  formation  of  cold  abscess 
and  sinuses.  Rheumatism  usually  involves  several  .joints, 
has  acute  onset,  is  transient,  with  marked  localized  tender- 
ness, and  if  severe,  redness  and  swelling. 

What  part  of  the  spinal  cord  is  involved  in  progressive 
muscular  atrophy? 

The  anterior  horns  of  the  gray  matter. 

What  are  the  degenerative  changes  of  arteries? 

Calcareous  infiltration,  hyaline,  fatty  and  amyloid  degen- 
eration. 

What  pathologic  changes  may  cicatrices  undergo? 

Cicatricial  contraction  or  distension,  cicatricial  keloid,  ci- 
catricial carcinoma,  abscess  and  ulceration. 


PATHOLOGY  AND  BACTERIOLOGY.  297 

What  is  ischemic  paralysis? 

The  loss  of  voluntary  motion  in  a  livinji-  part,  the  result  of 
local  anemia. 

Differentiate  between  a  tubercular  and  typhoidal  ulcer 
of  the  small  intestine. 

The  tubercular  ulcer  results  from  the  action  of  the  tubercle 
bacillus,  is  chronic,  tends  to  have  a  long'  axis  transverse  (an- 
nular ulcer)  to  bowel,  to  show  outlying  tubercles  and  irregu- 
larly thickened  edges  and  base.  The  typhoid  ulcer  results 
from  the  action  of  the  bacillus  of  E])erth.  tends  to  have  its 
long  axis  parallel  to  gut,  to  have  undermined  edges  and  thin 
floor,  and  often  causes  hemorrhage  or  perforation. 

Distinguish  between  burns  inflicted  on  a  body  before 
death  and  those  inflicted  after  death. 

Vesicles  containing  albuminous  serum  and  an  adjacent  red 
zone  of  inflammatory  reaction  indicate  infliction  of  burn  dur- 
ing life,  and  are  absent  in  case  of  burns  produced  after  death. 

Give  the  causes  of  hemorrhage. 

Increased  blood  pressure,  atheroma,  aneurysm,  fatty,  calca- 
reous, inflammatory  change  or  malignant  infiltration  of  vessel 
wall,  embolism,  traumatism,  hemophilia,  scurvy,  typhus  fever, 
venoms,  phosphorus  poisoning,  and  anomalous  innervation, 
as  in  hysteria. 

What  are  the  causes  of  lymphorrhagia? 

Lymphatic  obstruction  or  injury,  as  may  result  from 
trauma,  pressure  of  neoplasms,  aneurysms  or  inflammatory 
tissue,  or  obstruction  by  filaria  or  other  parasites. 

How  does  calcareous  degeneration  of  the  arteries  influ- 
ence the  circulation? 

Iiu'reases  arterial  juvssure  and  tlu'  work  of  heart,  causes 
imperfect  l)lood  supply,  at  times  leading  to  gangrene,  and 
favors  tlii'oiiibosis  and  hoiiioi-i'liage  (hemiplegia). 

What  are  pyogenic  bacteria? 

Sclii/.omycetos  capable  of  iiiaugiii'at  iiig  suppuration. 


298  PATHOLOGY  AND  BACTERIOLOGY. 

What  changes  take  place  in  simple  atrophy  of  the  liver? 

A  reduction  in  size,  with  preservation  of  general  outlines, 
and  without  noteworthy  increase  of  stroma,  or  degenerative 
<;hange  in  the  liver  cells. 

Describe  syphilitic  gummata. 

Rounded,  soft  or  firm,  grayish  or  yellowish,  circumscribed 
masses,  from  five  mm.  to  several  cm.  in  diameter,  surrounded 
by  an  area  of  fibro-connective  tissue,  and  consisting  of  a  typi- 
cal granulation  tissue  showing  mucoid  degeneration  or  cen- 
tral caseous  necrosis. 

What  changes  characterize  inflammation  of  bone? 

An  absorption  of  bone,  with  the  ingrowth  of  new  granu- 
lation tissue  (rarefying  ostitis)  or  possibly  abscess  formation, 
or  a  progressive  ossification  with  resulting  thickening  and 
condensation  (condensing  ostitis). 

Where  and  what  are  the  pathologic  changes  in  bulbar 
paralysis? 

Degenerative  atrophy  and  sclerosis,  with  shrinking  of 
motor  cells  and  degeneration  of  processes,  affecting  the  glosso- 
labio-laryngeal  nucleus  in  the  medulla. 

Give  the  pathologic  changes  in  sclerosis  of  nerves. 

An  overgrowth  of  the  supporting  connective  tissue  and 
neuroglia,  with  thickening  of  hlood- vessel  walls  and  atrophic, 
fatty  or  other  degenerative  changes  in  myelin  sheaths  and 
axis  cylinders. 

(a)  What  features  render  a  tumor  malignant?  (b) 
Mention  some  of  the  growths  considered  malignant. 

(a)  Invasion  of  adjacent  tissue,  recidivity,  metastasis,  the 
production  of  cachexia. 

(b)  Carcinoma  and  sarcoma  and  their  varieties. 

What  is  lardaceous  (amyloid,  waxy,  bacony)  degener- 
ation? 

The  transformation  of  tissue  into  a  homogeneous,  wax-like 


PATHOLOGY  AND  BACTERIOLOGY.  299 

albuminous  material,   giving  a   mahogany-brown   color   with 
dilute  Lugol's  solution. 

What  is  the  pathology  of  plastic  inflammation? 

A  modified  serum,  leukocytes  and  at  times  erythrocytes 
escape  from  the  vessels.  The  fibrin  factors  in  this  exudate 
unite,  producing  fibrin  that  may  cause  adhesion  between  con- 
tiguous viscera.  Later  this  plastic  exudate  may  break  down, 
or,  if  it  be  replaced  by  new  fibro-connective  tissue,  more  or 
less  permanent  adhesions  may  result. 

What  are  some  of  the  results  of  lymphorrhagia? 

Chylous  extravasation,  lymph  fistulae,  chyluria.  chylotliorax. 
-chylous  ascites,  malnutrition,  death. 

What  conditions  may  result  from  enlargement  of  lymph 
spaces  or  lymph  vessels? 

Capillary,  cavernous  or  cystic  lymphangioma,  cystic  hy- 
groma ("  hydrocele  of  the  neck  "),  macroglossia  (of  tongue), 
macrocheilia  (of  lip),  elephantiasis,  lymph  scrotum. 

What  inflammatory  conditions  may  result  in  enlarge= 
ment  of  the  lymphatic  glands? 

Infection  by  pyogenic  bacteria,  plague,  syphilis,  tubercu- 
losis. 

What  non=inflammatory  condition  may  produce  enlarge= 
ment  of  lymph  glands? 

Ilodgkin's  disease  (pseudoleukemia),  leukemia  (especially 
IjTuphatic  types),  lymphadenoma,  secondary  tumors  (carci- 
noma, sarcoma)  in  lymph  glands. 

Give  the  pathologic  features  of  mechanical  hyperemia 
of  the  liver  (nutmeg  liver). 

A  chronic,  passive  hyperemic  condition  resulting  from  val- 
vular heart  disease,  emphysema,  pleuritic  exudation,  aneu- 
rysm, or  other  obstructions  to  venous  return.  The  liver  is 
more  or  less  enlarged  and  is  deeply  mottled,  this  being  due  to 
the  distension  of  the  capillaries  near  the  center  of  the  lobules 
by  l)l()ud,  often  with  atrophy  of  the  adjacent  hepatic  cells, 


300     PATHOLOGY  AND  BACTERIOLOGY. 

while  the  liver  cells  at  the  periphery  of  the  lobules  may  show 
fatty  or  other  degenerative  changes. 

Describe  the  formation  of  an  acute  abscess. 

By  stages:  1.  Local  tissue  irritation,  usually  from  the  pres- 
ence of  pyogenic  bacteria.  2.  Exudation  of  modified  serum 
and  many  leucocytes.  3.  Colliquation  necrosis  in  affected 
area,  resulting  in  the  formation  of  cavity  (abscess)  filled  -wdth 
a  liquid  (pus),  consisting  of  fluid  part  (liquor  puris)  and 
many  dead  and  living  leucocytes  (pus  cells). 

Describe  symbiosis  with  special  reference  to  patho= 
genesis  and  cite  an  example. 

Symbiosis  refers  to  the  modifications  in  the  activities  of 
different  species  of  hacteria  resulting  from  their  association 
as  compared  with  their  activities  when  in  pure  culture.  Thus, 
the  injurious  aft'ects  of  the  tubercle  bacilli  upon  the  tissues 
are  greatly  increased  when  the  bacilli  are  in  association  with 
streptococci  or  staphylococci.  Upon  the  other  hand,  anthrax 
bacilli  become  less  virulent  when  mixed  with  cultures  of 
Bacillus  prodigiosus. 

Give  a  general  description  of  the  action  of  agglutinins. 

Agglutinins  are  substances  observed  chiefly  in  the  blood 
serum  of  infected  animals,  which  when  brought  in  contact  with 
li\ing  or  dead  bacteria  of  the  same  species  as  those  having 
produced  the  infection,  cause  the  bacteria  to  become  immotile, 
and  to  agglutinate  or  collect  in  clumps.  The  action  is  usually 
specific ;  that  is,  it  occurs  only  against  bacteria,  of  the  same 
species  as  that  causing  the  infection.  It  is  not  necessarily 
associated  with  the  death  of  the  bacteria,  and  as  agglutinins 
may  be  produced  by  the  action  of  bacteria  upon  culture 
media,  the  animal  body  is  not  essential  to  their  formation. 

Describe  the  process  of  ulceration. 

Ulceration  or  the  production  of  an  ulcer  is  an  inflammatory 
process  in  which  a  definite  loss  of  substance  from  a  surface 
of  the  body  is  produced.  The  area  may  be  destroyed  by  the 
injurious  action  of  physical  or  animate  agents,  by  interfer- 


PATHOLOGY  AND  BACTERIOLOGY.  301 

euces  with  the  circulation,  or  as  a  result  of  the  progress  of 
tumors.  The  tissue  of  the  involved  area  is  first  removed  by 
processes  of  necrosis,  or  mechanically.  The  area  left  has 
borders  of  more  or  less  healthy  tissue  which  become  the 
seat  of  extension  or  of  healing  of  the  ulcer;  and  a  floor  or 
base,  which  usually  becomes  occupied  by  granulations,  or, 
if  the  ulcer  be  progressive,  by  necrotic  and  sloughing  tissues. 
Ulceration  may  be  a  chronic,  indolent  process,  may  be  pro- 
gressive.- leading  to  extension  of  the  ulcer,  or  as  usually 
occurs,  it  may  become  arrested  and  cicatrization,  or  healing  of 
the  area,  may  occur. 

Describe  the  changes  that  occur  in  cartilage  in  arthritis 
deformans. 

The  cartilage  becomes  softened,  fissured,  and  develops  sur- 
face excavations  which  may  extend  deeply  into  the  bone. 
Simultaneously,  other  cartilage  cells  may  proliferate  and  pro- 
duce nodular,  cartilagnnous  projections.  ^Fedullary  spaces 
invade  the  degenerating  and  proliferating  cartilage,  and  it  is 
transformed  in  part  into  osteoid  tissue.  Villous  or  nodular, 
fatty,  calcareous  or  bony  outgrowths  may  spring  from  the 
synovial  membrane,  and  if  they  become  detached,  form  free 
joint  bodies.  The  bones  making  up  the  joint  become  more 
flattened,  more  porous,  excavated,  or  the  seat  of  new  bony  pro- 
cesses ;  and  fibrous  ankylosis,  subluxation  or  luxation  fre- 
quently follows. 

Enumerate  the  most  ordinary  senile  changes  that  occur 
in  the  various  tissues  of  the  body. 

In  organs,  atrophy  anl  increase  of  fibro-connective  tissue 
elements.  In  bones,  absorption  of  oseous  tissue,  and  cer- 
tain clianges  in  form,  especially  noted  in  thrTclentulous  man- 
dible, and  in  the  neck  of  tlie  femui-.  In  walls  of  arteries  and 
veins,  arteriosclerotic  changes,  with  tendency  to  calcification. 
In  joins,  degenerative  changes,  resembling  rheumatoid  arthri- 
tis of  a  inild  type.  In  skin  and  adi[)ose  tissue,  wasting  and 
atrophy. 


302  PATHOLOGY  AND  BACTEBIOLOGY. 

Describe  how  mitral  stenosis  and  aortic  regurgitation 
respectively  affect  the  cavities  and  musculature  of  the 
heart. 

In  mitral  stenosis,  as  the  left  ventricle  receives  insufficient 
blood,  it  may  atrophy.  As  the  left  auricle  insufficiently 
empties,  it  hypertrophies  and  dilates.  Secondarily,  the  back 
pressure  through  the  lungs  increases  the  work  of  the  right 
ventricle,  which  hypertrophies.  The  cavities  of  the  right 
ventricle  and  left  auricle  are  increased  and  their  walls  are 
thickened.  The  cavity  of  the  left  ventricle  decreases  in  size, 
and  has  unaltered  or  thinned  walls.  In  aortic  regurgitation, 
much  of  the  blood  which  has  left  the  left  ventricle  is  per- 
mitted to  return,  so  that  the  ventricle  receives  not  only  the 
normal  blood  from  the  left  auricle,  but  also  the  return  leak 
from  the  aorta.  This  results  in  distension  of  the  cavity  and 
compensatory  hypertrophy.  This  may  cause  an  enormous  in- 
crease in  the  thickness  and  size  of  the  ventricle.  Eventually 
the  ventricle  becomes  incompetent,  or  in  its  distension  pro- 
duces mitral  insufficiency,  and  there  ensues  an  auricular 
hypertrophy,  and  dilatation,  pulmonary  congestion,  and  fin- 
ally distension  and  hypertrophy  of  the  right  heart.  An 
enormous  heart  (cor-bovinum)  may  thus  be  produced. 

Describe  the  bacillus  tuberculosis,  its  habitat,  mode  of 
growth  and  method  of  detection. 

The  tubercle  bacillus  has  the  form  of  a  minute,  slightly 
curved  rod,  with  rounded  ends,  and  an  average  measurement 
of  2x.35  microns.  It  occurs  singly  and  in  small  groups.  Its 
habitat  is  the  tissues  of  vertebrates.  Precise  knowledge  of  its 
natural  growth  outside  of  the  body  is  wanting.  Its  growth 
under  artificial  cultivation  is  slow,  requiring  several  weeks 
for  colonies  to  develop,  and  necessitating  special  media,  such 
as  glycerine  agar,  or  special  blood  serum.  Pale  gray  or  yel- 
lowish, dry,  wrinkled,  rather  firm,  crustlike,  surface  masses 
are  formed  by  the  growth  of  the  bacteria.  Growth  usually 
occurs  only  at  a  temperature  about  that  of  the  body,  in 
the  absence  of  strong  light,  and  in  the  presence  of  free  oxygen. 


PATHOLOGY  AND  BACTERIOLOGY.  30a 

It  is  detected — (a)  by  inoculating  guinea-pigs  with  some 
of  the  suspected  material,  and  six  weeks  later  killing  them 
and  searching  for  the  characteristic  lesions  of  tuberculosis. 
Or — (b)  by  staining  spread  smears  of  suspected  material 
three  minutes  with  hot  carbol-fuchsin  and  decolorizing  for 
five  minutes  with  a  three  per  cent,  solution  of  HCl,  in  absolute 
alcohol.  Tubercle  bacilli  retain  the  red  fuchsin  color  after 
this  treatment,  while  nearly  all  other  bacteria  are  decolorized. 

Describe  the  microscopic  appearances  of  acute  paren= 
chymatous  nephritis  and  explain  the  origin  of  blood  in 
the  hemorrhagic  form. 

The  microscopic  changes  may  be  chiefly  of  the  glomeruli 
— glomerulo-nephritis,  or  in  convoluted  tubules — tubulo-ne- 
phritis.  or  may  affect  all  the  parenchyma.  In  the  capsular 
spaces  are  glomerular  or  desquamated  epithelial  cells,  leuko- 
cytes, erythrocytes  and  plastic  or  granular  exudate.  The 
epithelial  cells  may  show  cloudy  swelling,  fatty  metamor- 
phosis, or  karyokinetic  changes  indicating  regenerative  ef- 
forts. Where  the  walls  of  the  vascular  tuft  in  the  glomerulus 
give  way,  a  hemorrhage  occurs,  distends  the  capsules,  flows 
down  the  i-enal  tubules,  coagulates  there,  and  forms  blood 
casts.  The  cells  lining  the  tubules  (especially  the  convoluted) 
show  cloudy  swelling,  fatty  metamorphosis,  or  even  necrosis, 
and  hyaline,  granular,  cellular,  or  hemorrhagic  casts  fill  the 
tubules. 

Describe  the  pathologic  histology  of  amyloid  liver  and 
state  where  the  deposit  occurs. 

The  amyloid  substance  is  formed  in  the  connective  tissue 
framework  of  the  liver,  appears  in  or  about  the  walls  of  the 
capillaries,  as  anuclear,  homogeneous  cylinders,  and  as  irregu- 
lar wax-like  masses  in  the  tissues  which  displace  the  cells  of 
the  parenchyma,  and  perhaps  favor  the  atrophic,  fatty,  de- 
generative clianges  that  they  show.  The  amyloid  substance 
does  not  take  the  usual  nuclear  stain,  but  is  given  a  reddish 
color  by  gentian  violet. 


304     PATHOLOGY  AND  BACTERIOLOGY. 

Describe  the  lesions  characteristic  of  chronic  alcoholism. 

The  lesions  produced  by  chronic  alcoholism  also  occur  from 
other  toxic  causes,  and  it  is  difficult  to  state  that  any  are 
absolutely  characteristic  of  alcoholism  alone.  In  the  nervous 
system  a  form  of  multiple,  peripheral  neuritis  (alcoholic 
neuritis)  characterized  by  swelling,  redness,  infiltration,  and 
degeneration  that  may  be  perineural  or  interstitial,  occurs. 

The  myelin  may  be  degenerated,  and  the  axis  cylinders  show 
varicosities  or  granular  degeneration,  and  finally  may  be 
destroyed  and  replaced  by  connective  tissue  that  is  sometimes 
infiltrated  with  fat.  In  the  central  nervous  system  opaque 
thickening  of  the  meninges  with  wasting  of  the  cerebral 
convolutions,  are  common.  Hemorrhagic  pachymeningitis 
may  also  result.  The  liver  may  be  reduced  in  size  with  irre- 
gular surface,  increase  of  connective  tissue  framework,  and 
degeneration  of  parenchyma  (gin-drinkers'  liver).  The  typi- 
cal beer  drinkers'  liver  is  a  much  enlarged  organ  showing 
fatty  degeneration.  The  stomach  and  intestines  may  be  di- 
lated, the  atrophied  mucosa  being  the  seat  of  a  chronic 
catarrh  with  fibrous  interstitial  changes.  The  arteries 
usually  show  arterio-sclerotic  changes,  frequently  associated 
with  cardiac  dilatation.  The  superficial  capillaries  and 
venules,  especially  of  the  cheeks  and  nose,  are  dilated  and 
have  thickened  Myalls  (acne  rosacea).  The  kidneys  are  less 
affected  than  the  organs  of  the  digestive  tract,  but  are  often 
enlarged  or  contracted  and  show  arterio-sclerotic  changes. 
The  resistance  to  tuberculosis  and  other  infections  is  de- 
creased. 

Describe  why  and  how  obstructive  disease  of  the  cor= 
onary  arteries  causes  myocardial  degeneration. 

The  coronary  arteries  are  end  arteries  with  only  capillary 
anastomoses  between  their  terminal  branches,  and  supply  the 
myocardium  with  nutriment.  Therefore  unless  abnormal 
anastomoses  exist  or  a  vicarious  compensating  flow  through 
the  vessels  of  Thebesius  and  the  coronary  veins  occurs,  ob- 
struction to  the  circulation  in  the  coronary  arteries  results  in 


PATHOLOGY  AND  BACTERIOLOGY.  305 

ischemia  and  degeneration  or  death  of  the  heart  muscle  sup- 
plied by  the  obstructed  vessel.  A  coronary  thrombus  or  em- 
bolus causes  a  myocardial  infarct.  A  more  gradual  obstruc- 
tion may  lead  to  a  fibrous  myocarditis. 

Explain  the  pathological  characteristics  respectively  of 
exudative  and  productive  renal  degeneration. 

In  the  exudative  renal  degeneration  there  is  an  escape  of 
blood  serum,  leukocytes,  at  times  erythrocytes,  and  the  pro- 
ducts of  epithelial  cells,  into  the  capsules  of  Bowman,  the 
renal  tubules,  and  at  times  into  the  intertubular  connective 
tissue.  In  the  productive  renal  degeneration  there  is  a  new 
growth  of  fibro-connective  tissue  about  the  capsules  of  Bow- 
man, about  the  blood  vessels,  and  in  the  capsule  proper  of 
the  kidney.  Often  there  is  an  association  of  productive  and 
exudative  changes  in  the  same  organ. 

What  varieties  of  degeneration  may  occur  in  lymph 
glands? 

Fatty  degeneration,  pigmentary  infiltration,  calcification, 
hyaline  degeneration,  amyloid  degeneration. 

Mention  the  malignant  neoplasms. 

The  varieties  of  carcinoma,  including  epithelioma ;  sarcoma, 
and  its  varieties. 

What  tissues  are  most  frequently  the  seat  of  tubercular 
formation? 

In  order  of  frequency — lungs,  lymph  glands,  ileum  and 
larynx,  joints,  pleura,  meninges,  peritoneum,  bones,  spleen, 
kidneys  and  genito-urinary  organs. 

(a)  On  what  principle  are  tumors  classified?  (b)  Men- 
tion the  important  classes  of  tumors,  giving  an  example 
mnder  each  class. 

The  varieties  of  normal  tissue  that  they  typify. 

1.  Adult  connective  tissue  type,  as  fibroma. 

2.  Embryonic  connective  tissue  type,  as  sarcoma. 

20 


306  PATHOLOGY  AND  BACTERIOLOGY. 

3.  More  highly  specialized  tissue  type,  as  myoma,  neuroma^ 
lymphangioma. 

4.  Endothelial  type,  as  endothelioma. 

5.  Epithelial  type,  squamous,  columnar  or  glandular,  as 
squamous  papilloma,  columnar  epithelioma,  adeno-carcinoma^ 

6.  Tumors  of  mixed  type,  as  teratoma. 

What  pathologic  changes  may  result  from  cerebral 
hemorrhage? 

Cerebral  hematoma,  softening,  cyst,  cicatrix,  porencephalus^ 
atrophy  or  sclerosis.  Atrophy  of  voluntary  muscles  and 
cutaneous  tissues,  secondary  descending  sclerosis  of  motor 
paths. 

Give  the  process  of  tubercle  development. 

(1)  Lodgment  of  tubercle  bacilli,  (2)  Proliferation  of  epi- 
theloid  cells  and  an  invasion  of  lymphoid  cells  in  the  affected 
area,  (3)  Fusion  of  epitheloid  cells  with  formation  of  giant 
cells,  (4)  Central  coagulation  necrosis,  (5)  Fusion  of  adja- 
cent tubercles  with  caseation,  producing  yellow  tubercle. 

What  is  (a)  productive  inflammation?  (b)  Suppurative 
inflammation? 

(a)  One  characterized  by  the  formation  of  new  fibro-con- 
nective  tissue. 

(b)  One  characterized  by  the  formation  of  pus. 

What  structures  are  principally  involved  in  bubonic 
plague?     How  are  these  structures  affected? 

Lymphatic  glands — supperative  lymphadenitis ;  lungs — 
a  form  of  bronchopneumonia;  intestinal  tract — hemorrhagic- 
gastro-enteritis ;  kidneys — an  acute  intestitial  and  parenchy- 
matous nephritis ;  spleen — hyperplastic  splenitis. 

Mention  the  varieties  of  eczema. 

Squamous,  papular,  vesicular,  pustular,  impetiginous,  ec- 
zema parasiticum,  rubrum,  fissum,  impetiginodes,  marginatum,, 
papulosum,  vesiculosum,  pustulosum,  squamosum,  sclerosum^ 
seborrheicum,  ulcerosum. 


PATHOLOGY  AND  BACTERIOLOGY.  307 

What  pathologic  conditions  increase  the  elimination  of 
urea? 

Acute  fevers,  inflammation,  bacterial  infections,  in  dia- 
betes, rheumatism,  gout,  in  lithemia. 

Give  the  lesions  of  typhoid  fever. 

Catarrhal  entero-eolitis,  infiltration  and  hyperplasia  of 
Peyer's  patches,  terminating  in  necrosis  and  ulceration,  hem- 
orrhages, perforation  or  cicatrization.  Mesenteric  lympha- 
denitis. Splenic  hyperplasis,  parenchymatous  hepatitis  and 
nephritis.  At  times  degeneration  of  cardiac  or  voluntary 
muscles,  hypostatic  congestion  of  lungs  and  ulceration  of 
larynx  occur. 

What  pathologic  changes  take  place  in  the  blood 
plasma? 

Hypertonieity  (excess  of  salt)  hyperiuosis  (excess  of 
fibrin  factors)  ;  hypinosis — deficiency  in  fibrin  factors;  hy- 
dremia (excess  of  water)  ;  anhydremia — deficiency  in  water. 
Lipemia — contains  fat  droplets;  melanemia — contains  mel- 
anin; hemoglobinemia — contains  dissolved  hemoglobin.  Ab- 
normalities in  alkalinity. 

What  conditions  may  cause  dropsical  effusion  in  the 
abdomen  and  in  the  lower  extremities? 

Cirrhosis,  or  tumor  of  the  liver,  syphilitic  hepatitis,  valvu- 
lar heart  disease,  pulmonary  disease,  neoplasms,  parasites  or 
inflammatory  exudates  interfering  with  the  portal  circulation, 
tuberculous  peritonitis. 

Give  the  causes  and  pathologic  anatomy  of  lympha- 
denitis. 

Iiirtainiuation  of  lymphatic  glands  results  from  irritants, 
(■s[t('('ially  the  pyogenic  bacteria,  the  tubercle  bacillus  and  the 
bacillus  of  j)lagu('.  The  glands  are  enlarged,  hyperemic,  soft, 
[)ul[)y,  and  infilti-ated  by  serum  and  red  and  white  corpuscles, 
and  may  sup{)urate. 


308  PATHOLOGY  AND  BACTERIOLOGY. 

What  is  calciiic  metamorphosis? 

The  transformation  of  cells  into  a  calcareous  or  mineral 
substance. 

Name  some  of  the  causes  of  active  hyperemia  and  give 
illustrations. 

Paralysis  of  vaso-constrictor  or  stimulation  of  vaso-dilator 
nerves,  mechanic,  thermic  or  chemic  irritation,  as  shown  in 
blushing,  after  friction  of  skin,  application  of  heat  or  cold, 
or  action  of  bacterial  or  drug  irritants. 

Illustrate  and  define  hypostatic  inflammation. 

When  the  circulation  is  insufficient  the  blood  tends  to  settle 
or  stagnate  in  dependent  parts  of  the  body  (hypostatic  con- 
gestion), and  a  form  of  inflammation  may  ensue  (hypostatic 
inflammation),  such  as  the  hypostatic  pneumonia  occurring 
in  low  forms  of  typhoid  fever. 

What  are  some  of  the  phenomena  attending  pus  for= 
mation? 

Heat,  redness,  swelling,  tenderness,  throbbing  pain,  soften- 
ing of  tissue,  fluctuation,  pointing. 

Describe  the  pathologic  conditions  in  hectic  fever. 

Hectic  fever  is  a  persistent  form  characterized  by  high 
exacerbations  at  night,  and  resulting  from  microbic  action, 
and,  as  a  rule,  the  formation  of  pus  within  the  body. 

What  are  pathologic  conditions  causing  favus? 

The  proliferation  in  the  hair  follicles  of  a  mold,  achorion 
schoenleinii. 

How  are  secretions  affected  in  anemia? 

Usually  decreased,  although  the  urine  may  be  increased 
either  in  bulk  or  relative  solid  contents,  while  the  free  hydro- 
chloric acid,  which  may  be  absent  from  the  gastric  secretion 
in  progressive  anemia,  may  be  present  in  increased  amount 
in  chlorosis. 


PATHOLOGY  AND  BACTERIOLOGY.  309 

What  organs  are  most  subject  to  tuberculosis? 

Lungs,  lymph,  glands,  serous  membranes,  bones,  spleen, 
kidneys,  adrenals,  genital  organs,  bladder,  skin. 

Name  some  of  the  changes  which  occur  in  extravasated 
blood. 

Coagulation,  solution,  replacement  by  granulation  tissue, 
decomposition  anl  suppuration,  desiccation  and  scabbing. 

What  glands  are  most  frequently  affected  by  amyloid 
degeneration? 

Liver,  spleen,  kidneys,  lymph  glands. 

To  what  diseases  does  calcareous  degeneration  of  the 
arteries  predispose? 

Aneurysm,  hemiplegia,  cerebral  softening,  dry  gangrene. 
Give  the  varieties  of  tubercle. 

Reticulated  tubercle,  lymphoid  tubercle,  epithelioid  tubercle, 
miliary  tubercle,  submiliary  tubercle,  gray  tubercle,  yellow 
or  crude  tubercle  of  Laennec. 

(a)  What  are  bacteria?  (b)  What  conditions  are  favor= 
able  to  their  increase,  and  (c)  what  is  meant  by  their  toxic 
products? 

(a)  Fission  fungi  or  schizomycetes.  (b)  Warmth,  moist- 
ure, albuminous  media,  usually  best  if  of  neutral  or  slightly 
alkaline  reaction,  absence  of  strong  actinic  rays,  (c)  Poison- 
ous substances,  toxins,  ptomaines  or  bacterial  proteids  formed 
by  or  in  bacteria. 

Name  some  of  the  principal  bacteria  of  the  staphylo^ 
cocci  and  the  streptococci  groups. 

Staphylococcus  aureus,  staphylococcus  albus,  staphylococ- 
cus citreus,  streptococcus  pyogenes,  streptococcus  erysipelatis. 

Name  the  important  pathogenic  diplococci. 

Diplococcus  gonorrhoea,  diplococcus  pneumonine.  diplococ- 
eus  meningitidis  capsulatus  of  Weichselbaum. 


310  PATHOLOGY  AND  BACTERIOLOGY. 

What  changes  take  place  in  cyanotic  atrophy  of  the 
liver?  Give  the  microscopic  appearance  of  this  diseased 
condition. 

A  persistent  passive  congestion  with  secondary  hyper- 
plasia of  the  connective  tissue  and  pigmentation  of  hepatic 
cells;  microscope  shows  wide  dilatation  of  capillaries  and 
veins,  with  atrophy  and  pigmentation  of  hepatic  cells  and 
overgrowth  of  perilobular  connective  tissue. 

Define  and  illustrate  bacilli,  micrococci,  spirilla. 

(a)  Bacilli  are  rod-shaped;  micrococci,  spherical  shaped; 
spirilla,  spiral-shaped  bacteria.  (b)  Bacillus  tuberculosis, 
micrococcus  ureae,  spirillum  cholera?. 

Give  the  pathologic  features  of  angioleucitis  (lymphan= 
git is). 

The  lymph  vessels  are  inflamed,  red,  swollen  and  distended 
by  a  cell-laden  liquid.  Their  walls  are  edematous,  infiltrated 
by  leukocytes,  and  may  be  broken  down  if  the  process  be  sup- 
purative. The  cause  is  almost  invariably  micro-organismal, 
and  there  is  usually  an  associated  lymphadenitis. 

Mention  the  structural  changes  that  occur  in  tubercular 
joints. 

Tubercles  in  the  synovial  membrane,  subsynovial  tissue  or 
cancellous  bone.  Diffuse  (tumor  albus)  or  nodular  (synovitis 
tuberosa)  thickening  of  synovial  membrane,  or  distension  of 
joint  with  inflammatory  serum  (hydrops)  or  puriform  liquid 
(empyema);  erosion  of  cartilage  and  bone;  tuberculous  ab- 
scess and  sinus  formation. 

Give  the  possible  causes  of  occlusion  of  the  bile=duct. 

Catarrhal  swelling  of  mucous  lining,  lodgment  of  calculus 
or  parasitic  worm  (as  ascaris  lumbricoides  or  distoma  hepa- 
tinum) ,  invasion  by  coccidia,  cicatricial  contraction  of  walls 
of  duct,  pressure  from  without  by  an  adjacent  tumor  or 
floating  kidney,  involvement  in  a  neighboring  carcinoma,  sar- 
coma, endothelioma  or  an  inammatory  process,  duodenal 
disease  involving  the  terminal  papilla. 


PATHOLOGY  AND  BACTERIOLOGY.  311 

(a)  What  causes  contribute  to  obesity?  (b)  What  tis= 
sues  are  most  frequently  invaded  in  obesity? 

(a)  Anemia,  hemorrhages,  use  of  malt  liquors,  lack  of  exer- 
cise, hereditary  tendency,  over-eating,  certain  dyspepsias. 

(b)  The  subcutaneous  tissues  and  subserous  tissues  of  ab- 
domen, especially  about  kidneys,  in  great  omentum  and  ap- 
pendices epiploic??. 

In  what  order  are  the  organs  of  the  thorax  and  abdo= 
men  best  examined  at  a  post=mortem  section? 

Authorities  differ.  The  following  is  useful :  Inspection  of 
abdominal  cavity,  inspection  of  pleura,  pericardium,  heart 
and  vessels,  examination  of  heart,  lungs,  organs  of  neck, 
spleen,  gastro-intestinal  tract,  liver,  pancreas,  genito-urinary 
organs,  abdominal  aorta  and  sympathetic  ganglia. 


THERAPEUTICS  AND  MATERIA  MEDICA 


Mention  the  salts  of  lithium  and  describe  their  medici= 
nal  uses.    -    ^/p  *^ 

Benzoate,  bromide,  carbonate,  citrate,  and  salicylate.  The 
carbonate  and  citrate  are  used  extensively  in  gout  and  the 
lithemie  diathesis.  The  lithium  salts  have  strong  alkaline 
((ualities,  and  act  on  the  system  as  other  alkalies.  Lithium, 
bromide  is  prescribed  for  the  effects  of  bromide. 

What  are  the  therapeutic  uses  of  lobelia? 

It  is  used  as  an  expectorant,  diaphoretic,  emetic,  purgative, 
and  anti-spasmodic. 

Mention  the  official  preparations  of  copper.  Give  the 
dose  of  each. 

There  is  but  one  official  preparation,  the  sulphate,  which  is 
given  as  an  emetic  in  doses  of  0.250  Gm.  (4  grains),  and  as  a 
tonic  in  dose  of  0.010  Gm.  (i/r;  grain). 

What  are  the  therapeutic  uses  of  oleum  tiglii  or  Croton 
oil? 

Externally  it  is  applied  as  a  counter-irritant  in  bronchitis, 
neuritis,  rheumatism,  and  ovaritis.  Internally  it  is  used  as  a 
prompt  hydragogue  catharitic  and  revulsant  in  acute  cerebral 
congestion,  apoplexy  and  uremia.  In  these  cases  it  not  only 
causes  general  depletion,  but  also  a  rapid  efflux  of  blood  from 
the  brain. 

What  are  the  uses  of  the  bromides? 

The  bromides  are  used  as  sedatives  to  the  nervous  system^ 
to  lower  reflex  activity,  to  produce  sleep,  to  subdue  excite- 

(  313  ) 


814      THERAPEUTICS  AND  MATERIA  MEDICA. 

ment  of  the  genital  apparatus,  and  to  antagonize  congestion 
of  the  brain. 

Give  the  indications  for  the  use  of  corrosive  sublimate 
internally. 

As  an  antisyphilitic,  as  a  hematinic,  and  general  alterative 
in  gastric  ulcer  and  early  stages  of  hepatic  cirrhosis  and  in 
dysentery. 

What  remedies  are  employed  to  correct  anemic  condi= 
tions  and  how  are  they  used? 

Nux  vomica,  stimulates  the  blood-making  organs,  and  is 
used  as  an  ad.junct  to  restorative  remedies.  Iron,  the  chief 
value  of  which  is  to  improve  digestion  and  to  furnish  hematin 
to  the  blood.  The  astringent  preparations  are  the  best,  and 
should  be  given  after  meals.  Arsenic  as  an  adjunct  to  iron. 
Arsenic  increases  the  number  of  blood  cells,  while  the  iron 
increases  the  hemoglobin  contained  in  each.  Bichloride  of 
mercury,  quinine  and  manganese  increase  the  number  of  red 
blood  cells.  In  the  treatment  of  anemia  it  is  of  importance 
to  determine  the  cause  when  possible.  This  will  frequently 
be  found  to  be  due  to  gastro-intestinal  irritation  or  constipa- 
tion. General  tonic  treatment,  with  the  proper  diet  and 
hygienic  surroundings,  are  often  more  valuable  than  drug 
treatment. 

Describe  the  therapeutic  uses  of  the  preparations  of 
phosphorus. 

Phosphorus  is  chiefly  used  to  promote  the  nutrition  of 
osseous  and  nerve  tissue.  Very  small  doses  of  the  drug 
have  been  found  of  excellent  service  in  functional  impotence, 
in  certain  skin  diseases,  in  pernicious  anemia  and  in  neuralgia. 
Calcium  phosphate  and  the  hypophosphites  are  used  with 
benefit  in  all  diseases  of  malnutrition  and  where  the  repair 
or  development  of  the  bones  is  required.  They  are  particu- 
larly useful  in  protracted  suppuration,  osteomalacia,  rachitis, 
caries,  chronic  phthisis,  and  in  the  anemia  and  bone-softening 
of  lactation.    Sodium  phosphate  is  a  well-known  purgative. 


THERAPEVTICS  AND  MATERIA  MEDIC  A.      :U5 

Properly  write  a  prescription,  and  explain  each  of  its 
technical  component  parts  or  characteristics. 

March  1,  1910.  For  Mr.  John  Jones. 

R     Kalii  citratis. 3  'ii 

Spiritus  aetheris  nitrosi 3  i^ 

Aquae  menthae  piperitae §  i 

Syrupi  aurantii  cortici  q.  s.  ad %\n 

M.  Sig. — One  teaspoonful  in  water  every  two  hours. 

John  Smith,  M.  D. 

A  prescription  consists  of:  (1)  Superecription.  or  name. 
(2)  Inscription,  which  includes  (a)  the  base,  (b)  adjuvant, 
(c)  corrective,  (d)  vehicle  or  exeipient.  (3)  Subscription  or 
directions  to  the  compounder.  (4)  Signature  or  direction 
to  the  one  who  gives  the  medicine,  ending  with  the  date  and 
preseriber's  signature. 

What  is  understood  by  the  term  antitoxin  unit,  and 
what  does  it  signify? 

A  normal  antitoxin  serum  is  one  that  contains  in  each  Cc. 
one  immunity  unit.  An  immunity  unit  is  the  amount  of  anti- 
toxic serum  which  will  minimze  100  times  the  minimum 
lethal  dose  of  toxin,  when  the  serum  and  toxin  mixed  and 
injected  into  a  250  gramme  guinea  pig  does  not  cause  death 
in  four  days. 

Name  five  astringent  drugs  and  state  to  what  the  astrin- 
gency  is  due. 

Asti-ingonts  may  act  by  causing  coagulation  of  albumin, 
contraction  of  unstriped  muscle  fibre,  contracting  capillaries, 
or  gland  ducts,  and  lessening  peristalsis. 

Tannic  acid,  hamamelis,  kino  and  aromatic  sulphuric  acid 
constrict  ti.ssues  and  coagulate  albumin. 

Bismuth  salts  form  a  protective  coating  over  exposed  or 
inflamed  surfaces. 

Plumbi  subacetatis  constricts  tissues  and  favors  clot  forma- 
tion. 


316      THERAPEUTICS  AND  MATERIA  MEDICA. 

Indicate  the  manner  in  which  ethylic  ether  (sulphuric 
ether?)  should  be  applied  to  produce  general  anesthesia. 

As  an  anesthetic  it  may  be  administered  from  a  sponge,  a 
folded  towel  surrounded  by  a  cone  of  pasteboard,  or  from  an 
inhaler  made  especially  for  the  purpose.  At  first  the  inhaler 
should  be  held  some  distance  from  the  nose,  to  accustom  the 
patient  to  the  irritant  effects  of  the  ether,  but  soon  it  should 
be  brought  close  to  the  nose,  so  that  the  anesthetic  may  be 
taken  in  concentrated  form.  Insensibility  of  the  conjunctiva 
and  muscular  reaction  are  the  indications  that  the  patient 
is  properly  prepared  for  the  operation.  Many  surgeons  now 
employ  preliminary  anesthesia  with  nitrous  oxide  gas.  This 
greatly  shortens  the  first  stage  and  allows  the  patient  to  be 
anesthetized  with  a  comparatively  small  amount  of  ether. 

In  what  manner  is  the  system  affected  by  an  overdose 
of  chloral  hydrate? 

The  ingestion  of  a  toxic  dose  produces  sleep,  which  soon 
deepens  into  coma ;  the  pulse  becomes  feeble  and  thready,  the 
respiration  embarrassed,  the  surface  cold  and  clammy,  the 
pupils  at  first  contracted  and  then  dilated,  and  finally  death 
results  from  cardiac  and  respiratory  paralysis. 

Name  three  general  anodynes  and  give  the  dose  of  some 
official  preparation  of  each. 

Opium,  belladonna,  cannabis  indica.  Morphine  sulphate, 
0.015  Gm.  (14  grain).  Sulphate  of  atropine,  0.0004  Gm. 
(V160  grain).    Extract  cannabis,  0.010  Gm.  (Vs  grain). 

State  the  precautions  which  should  ordinarily  be  ob= 
served  in  administering  medicines  by  the  hypodermic 
method. 

The  medicine  must  be  in  solution,  and  the  latter  should  be 
neutral  in  reaction  and  freshly  prepared.  The  skin  of  the 
patient  should  be  rendered  aseptic  at  the  place  selected  for 
the  injection.  The  solution  is  to  be  injected  beneath  the  skin 
and  not  into  it,  and  the  blood-vessels  and  nerve  points  are  to 
be  especially  avoided. 

/ 


THERAPEUTICS  AND  MATERIA  MEDICA.      317 

Give  the  physiological  effects  of  cinchona. 

Cinchona  is  an  astringent  bitter  and  a  stomach  tonic.  At 
first  it  promotes  appetite,  digestion,  the  flow  of  saliva  and 
gastric  juice;  long  continued  it  sets  up  a  gastric  catarrh,  im- 
peding digestion  and  causing  constipation.  Its  action  is  more 
astringent  and  irritating  than  that  of  its  alkaloid,  quinine. 
Its  active  principles  are  more  slowly  absorbed  by  reason  of 
its  bulk.  In  large  doses  quinine  causes  headache,  ringing  in 
the  ears  and  some  deafness.  It  is  antipyretic  and  a  heart 
depressant.  On  the  nervous  system  it  causes  congestion  of 
the  brain  and  acts  as  a  cerebral  excitant;  moderate  doses 
lessen  reflex  activity  by  stimulating  Setschenow's  inhibitory 
center.  Toxic  doses  permanently  abolish  the  reflexes  by  de- 
pressing the  spinal  cord  and  peripheral  nerves.  Small  doses 
■exert  no  influence  on  the  respiratory  system,  but  large  doses 
paralyze  the  respiratory  center. 

Mention  the  conditions  that  cbntra=indicate  the  admin= 
istration  of  aconite. 

It  is  contra-indicated  when  there  is  adynamic  action  of  the 
heart,  cardiac  degeneration  or  dilatation,  and  gastro-intestinal 
ii'ritation  or  inflammation. 

Mention  the  alkaloids  of  nux  vomica. 

It  contains  two  alkaloids,  strychnine  and  brucine.  The 
latter  resembles  the  former  in  its  action,  but  is  less  powerful. 

For  what  pathologic  conditions  is  salicylic  acid  admin  = 
istered?  What  symptoms  indicate  the  discontinuance  of 
the  use  of  salicylic  acid? 

Externally  it  is  used  as  an  antiseptic  in  the  dressing  of 
wounds.  Dissolved  in  collodion  it  is  a  valuable  application 
for  the  removal  of  corns.  The  ointment  is  of  service  in 
chronic  eczema.  Internally,  salicylic  acid  is  of  the  greatest 
value  in  acute  rheumatism.  In  neuralgia  and  neuritis  of 
rheumatic  origin  it  is  of  service,  as  it  is  in  tonsilitis,  pleurisy 
with  serous  effusion  and  in  diabetes  of  gouty  origin.  It. 
should  bo  discontiniifd  if  the  patient  suffers  from  headache. 


318      THERAPEUTICS  AND  MATERIA  MEDIC  A. 

riuging  in  the  ears,  deafness,  paralysis  of  the  ocular  muscles, 
great  fall  of  temperature,  excessive  sweating,  difficult  respi- 
ration, weak  pulse,  convulsions,  and  olive-green  urine.  These 
ar-e  the  symptoms  resulting  from  a  poisonous  dose. 

For  what  conditions  should  (a)  tincture  of  digitalis  be 
given,  (b)  infusion  of  digitalis  be  given?  Mention  the 
dose  of  each. 

When  the  cardiac  action  of  digitalis  is  desired  the  tincture 
should  he  employed,  and  no  fluid  should  be  taken  within 
twenty  minutes  either  before  or  after  swallowing.  If  the 
diuretic  action  is  required  the  proper  preparation  is  the  in- 
fusion. The  dose  of  the  tincture  is  1  Cc.  (15  minims).  The 
dose  of  the  infusion  is  8  Cc.  (2  fiuidrachms). 

Write  a  prescription  illustrating  chemical  incompati= 
bility. 

Salicylic  acid  is  incompatible  with  the  salts  of  iron ;  a  pre- 
scription containing  tincture  of  iron  and  salicylic  acid  would 
furnish  an  example  of  such  incompatibility. 

Mention  the  principal  physiologic  effects  of  jaborandi. 
Give  the  alkaloids  of  jaborandi. 

Jaborandi  is  a  powerful  diaphoretic  and  sialogogue,  a  car- 
diac depressant,  by  stimulation  of  the  vagus-ends ;  it  is  also 
myotic,  emetic,  and  under  some  circumstances  abortifaeient. 
Jaborandi  contains  four  alkaloids,  pilocarpine,  jaborine,  pilo- 
carpidine,  and  jaboridine. 

What  are  the  earliest  signs  of  poisoning  from  the  ex= 
ternal  use  of  carbolic  acid? 

Early  symptoms  are  smoky  color  of  the  urine,  lumbar  pain, 
slight  cerebral  disturbance,  after  which  develops  impairment 
of  respiration  and  stupor.  Applied  in  concentrated  form  it 
is  irritant  and  superficially  escharotic,  and  produces  at  the 
point  of  application  a  white  spot,  changing  to  red  if  the 
acid  is  soon  removed.  If  the  application  is  prolonged  a  white 
slough  results  from  coagulation  of  the  albumin  of  the  tissue; 
this  is  borcU^red  bv  a  red  zone  of  inflammation. 


THERAPEUTICS  AND  MATERIA  MEDICA.      319 

Mention  the  ingredients  and  the  dose  of  pulvis  glycyr- 
rhizae  compositus. 

Compound  liquorice  powder  contains  senna  18,  glj'cyrrhiza 
23.6,  oil  of  fennel  0.4,  washed  siilphnr  8,  sugar  50 ;  the  dose 
is  4  Gm.  (60  grains). 

For  what  conditions  should  blisters  be  applied?  De= 
scribe  the  application  of  blisters. 

Blisters  are  applied  for  the  purpose  of  producing  counter- 
irritation.  The  proper  manner  of  employing  a  counter-irri- 
tant to  affect  inflammation  is  not  to  apply  it  directly  to  an 
actually  inflamed  area,  but  a  little  to  one  side  of  it,  at  a  spot 
known  to  be  connected  intimately  with  the  diseased  area  by 
nerve  fibers. 

By  what  other  name  is  liquor  potassi  hydroxidi  known? 
State  the  dose. 

Liquor  pot-assi  hydroxidi  is  also  called  solution  of  potas- 
sium hydroxide.  Its  dose  is  1  Cc.  (15  minims),  well  diluted 
with  water. 

Mention  the  antagonist  of  cocaine. 

Ammonia  and  amyl  nitrite  combat  the  earliest  symptoms 
of  cardiac  depression  produced  by  cocaine.  The  most  direct 
antagonist  is  chloral ;  then  follow  chloroform,  ether  and  mor- 
phine. 

In  what  conditions  is  gallic  acid  useful? 

<iallic  acid  and  its  congener,  tannic  acid,  are  astringents, 
the  former  being  the  feebler  of  the  two.  They  constrict 
the  muscular  tissue  in  the  walls  of  the  minute  vessels,  thus 
checking  secretion  and  hemorrhage  and  cutting  short  local 
inflaiinnation.  Gallic  acid  is  useful  in  hematuria,  passive 
hemorrhages,  chronic  cystitis,  chronic  diarrhea,  bronchorrhea 
and  night  sweats. 

Describe  the  treatment  of  night  sweats. 

The  following  drugs  arc  found  useful  in  the  treatment  of 
night  sweats:  Sulphate  of  atropine,  in  doses  of  l-75th  gr.  at 


^20      THERAPEUTICS  AND  MATERIA  MEDICA. 

bed-time;  gallic  acid,  in  15  gr.  doses;  camphoric  acid,  in  10 
gr.  doses;  and  agaricine,  in  doses  of  y\  to  ^  gr.  Sponge  baths 
with  weak  solutions  of  alum  and  other  astringents  are  some- 
times employed. 

For  what  purposes  are  diuretics  employed? 

Diuretics  are  administered  with  the  object  of  increasing 
the  quantity  of  urine  excreted ;  to  promote  the  elimination  of 
waste  products  and  other  poisons  from  the  blood;  to  dilute 
the  urine  and  to  alter  morbid  conditions  of  the  urine. 

Give  the  source,  the  common  name,  and  the  principal 
therapeutic  uses  of  oleum  theobromatis. 

Oil  of  theobroma  is  commonly  called  cacao-butter.  It  is  a 
fixed  oil  expressed  from  the  seeds  of  theobroma  cacao,  the 
chocolate  tree,  which  is  found  in  Mexico,  the  West  Indies, 
and  South  America.  Oil  of  theobroma  consists  chiefly  of 
stearin  with  a  little  olein.  It  has  a  demulcent  action.  Its 
chief  use  is  as  a  base  for  making  suppositories. 

What  are  the  varieties  of  sinapis  used  in  medicine? 
How  are  they  used  and  for  what  purpose? 

There  are  two  varieties  of  sinapis  (mustard),  sinapis  alba 
and  sinapis  nigra.  It  is  directed,  however,  that  pharmaco- 
pceial  preparations  be  made  from  black  mustard  only.  Lo- 
cally used,  mustard  is  rubefacient,  counter-irritant,  and  a 
nerve  stimulant,  causing  heat,  redness  and  severe  burning 
pain.  Its  prolonged  application  produces  vesication  by  in- 
ducing local  inflammation.  Internally  it  is  a  local  emetic  in 
full  doses;  in  smaller  doses,  it  has  a  carminative  action.  On 
the  gastric  mucous  membrane  its  irritant  effect  is  much  less 
powerful  than  on  the  skin.  Mustard  is  commonly  used  as 
an  application  to  relieve  local  pain  and  to  produce  counter- 
irritation.  Internally  it  may  be  employed  as  an  emetic  in 
indigestion  or  narcotic  poisoning.  Its  use  as  a  condiment  is 
general.  The  oil  of  mustard  is  one  of  the  most  irritant  of 
the  volatile  oils,  producing  severe  gastro-enteritis. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      321 

What  are  the  causes  and  treatment  of  urticaria? 

Urticaria  in  an  inflammatory  affection,  characterized  by  the 
eruption  of  pale-red,  evanescent  wheals,  which  are  associated 
with  severe  itching.  It  is  due  to  gastro-intestinal  disturb- 
ances and  emotional  excitement.  Chronic  \asceral  diseases 
predispose.  It  is  produced  in  susceptible  individuals  by  cer- 
tain articles  of  food,  as  well  as  by  the  bites  of  insects,  and  by 
certain  drugs.  Treatment:  Remove  the  cause  when  possible. 
Especial  attention  should  be  paid  to  removing  gastric  irrita- 
tion and  securing  a  free  movement  of  the  bowels  with  a  saline 
laxative.  The  special  remedies  recommended  are  the  alkalies, 
salicylate  of  sodium,  quinine,  iodide  of  potassium,  atropine, 
and  antipyrine.  Locally,  lotions  of  water  and  alcohol,  car- 
bolic acid,  boric  acid  or  hydrocyanic  acid  are  very  useful. 

Name  three  drug:s  belonging  to  each  of  the  following 
classes:  narcotics,  diaphoretics,  ecbolics. 

Narcotics:  opium,  hyoscyamus  and  alcohol.  Diaphoretics: 
pilocarpine,  aconite  and  cocaine.  Ecbolics :  ergot,  oil  of  rue, 
and  savin. 

What  are  the  physiological  effects  and  the  therapeutic 
uses  of  Phytolacca? 

Phytolacca  is  an  emeto-cathartic  possessing  slow  but  per- 
sistent action,  with  great  nausea  and  considerable  depression. 
It  lowers  the  rate  of  respiration  and  of  cardiac  action,  and  is 
a  motor  depressant,  paralyzing  the  spinal  cord  and  the  me- 
dulla. Death  occurs  from  paralysis  of  respiration  preceded 
hy  tetanic  convulsions.  The  drug  is  said  to  possess  alterative 
properties,  and  has  been  used  internally  and  externally  in 
chronic  rheumatism  and  chronic  skin  affection.  It  causes 
absorj)ti()n  of  adipose  tissue,  and  has  been  used  as  a  remedy 
in  obesity.  Considering  its  physiologic  action  its  employment 
is  not  justifiable. 

From  what  sources  besides  nux  vomica  is  strychnine 
obtained?  What  other  alkaloid  is  obtained  from  the  same 
source? 

Strychnine  is  derived  from  Ignatia,  St.  Ignatius'  Bean, 
21 


322      THEBAPEUTIC8  AND  MATERIA  MEDICA. 

whieli  contains  the  alkaloids,  strychnine  and  brucine,  about 
1  per  cent,  of  each. 

How  do  borax  and  boric  acid  differ  chemically  and  thera= 
peutically? 

Boric  acid,  H3BO3,  is  a  weak  acid  occurring  in  transparent, 
colorless,  six-sided  plates.  It  is  odorless,  of  a  slightly  bitter 
taste,  and  is  soluble  in  18  parts  of  water,  in  15.3  of  alcohol 
and  in  4.6  of  glycerine  at  25°  C.  Borax  is  the  sodium  borate 
NaoB^O^  +  lOHoO ;  it  occurs  in  colorless,  transparent  prisms 
of  cooling  and  sweetish  taste  and  alkaline  reaction.  It  is 
soluble  in  20.4  parts  of  water  at  25°  C,  and  is  insoluble  in 
alcohol.  Boric  acid  may  be  produced  from  borax  by  the 
action  of  sulphuric  acid.  The  action  of  borax  differs  from 
that  of  boric  acid  in  being  a  more  powerful  antiseptic  and 
disinfectant,  as  well  as  being  far  more  irritating  when  locally 
applied. 

Name  the  official  preparations  of  gold  and  describe  its 
therapeutic  uses. 

Gold,  auriim,  has  but  one  official  salt,  the  gold  and  sodium 
chloride,  but  triturations  of  the  metal  itself  may  be  prepared 
according  to  the  general  pharmacopceial  formulae  for  such 
preparations.  Gold  has  been  recommended  in  certain  forms 
of  gastric  disturbances,  in  chronic  Bright 's  disease,  in  certain 
nervous  disorders,  in  impotence,  and  in  pertussis.  It  is  not 
generally  employed. 

What  is  the  adult  dose  of  (a)  sulphate  of  atropine,  (b) 
tincture  of  cantharides,  (c)  tincture  of  colchicum? 

(a)  0.0004  Gm.  (Vieo  grain),  (b)  0.3  Cc.  (5  minims), 
(c)  2  Cc.  (30  minims). 

Mention  three  alkaloids  which  are  chemically  alike  and 
almost  identical  in  physiologic  effect. 

Cinchoninae  Sulphas,  Cinchonidinge  Sulphas  and  Quinidinge 
Sulphas. 

State  the  cause  and  give  the  treatment  of  trichinosis. 

Trichinosis  is  a  typhoid  condition  resulting  from  the  en-^ 


THERAPEUTICS  AND  MATERIA  MEDIGA.      323 

trance  of  a  parasite,  the  trichina  spiralis,  into  the  intestinal 
canal  and  the  subsequent  migration  of  these  parasites  into 
the  muscular  structure.  The  trichince  are  introduced  into  the 
human  body  by  eating  infected  hog's  flesh,  either  raw  or  im- 
perfectly cooked.  The  preventive  treatment  consists  in  eating 
no  pork  that  has  not  been  perfectly  cooked.  If  the  parasites 
have  been  recently  taken,  emetics  and  purgatives  are  indi- 
cated. After  migration  has  begun  the  powers  of  life  should 
be  sustained  by  nourishing  food,  stimulants  and  tonics. 

What  drug  is  antagonistic  to  pilocarpine? 

Atropine  in  dose  of  1-100  gr,  for  each  %  gr.  of  pilocarpine. 
Where  is  the  habitat  of  belladonna? 

It  is  indigenous  in  the  mountainous  districts  of  central 
and  southern  Europe  and  Asia,  and  is  cultivated  in  Europe 
and  in  the  United  States. 

What  are  the  sources  of  sulphur? 

Sulphur  is  obtained  native  in  several  volcanic  districts,  or 
from  the  native  sulphides  of  iron  and  copper  by  roasting,  as 
it  sublimes  at  about  238°  F. 

In  what  dose  may  the  oil  of  wintergreen  be  adminis- 
tered to  an  adult  for  rheumatism? 

Average  dose,  1  Cc.  (15  minims). 

How  is  nitrite  of  amyl  administered  and  for  what  pur- 
pose? 

Nitrite  of  amyl  is  indicated  for  the  same  general  conditions 
as  nitroglycerin.  It  is  generally  prescribed  in  glass  pearls 
containing  3-5  minims,  and  these  are  broken  in  a  handker- 
chief and  inhaled.  It  is  a  valuable  heart  stimulant,  checks 
spasms  and  dilates  peripheral  vessels.  It  is  especially  em- 
ployed for  the  relief  of  attacks  of  angina  pectoris. 

Describe  the  therapeutic  uses  of  sparteine  and  state  the 
dose  of  the  sulphate  for  hypodermic  uses. 

Sparteine   is   the  alkaloid   of   Scoparius,   broom,   and   is  a 


324      THERAPEUTICS  AND  MATERIA  MEDICA. 

valuable    diuretic   and   heart  stimulant.      Its   dose  hypoder- 
mically  is  0.010  Gm.  (1/5  grain). 

What  are  the  physiologic  effects  and  the  therapeutic 
uses  of  the  balsam  of  Peru? 

Balsam  of  Peru  is  employed  locally  as  a  sedative  and  para- 
siticide. Internally  it  is  of  value  as  an  expectorant  in  chronic 
bronchitis.  This  balsam  is  antiseptic,  disinfectant,  stimulant 
to  the  circulation  and  sedative  to  the  nervous  system,  acting 
chiefly  on  the  mucous  membrane;  it  is  a  tonic  and  expec- 
torant, diuretic  and  diaphoretic. 

Give  the  common  name,  therapeutic  uses  and  dose  of 
sodium  sulphate. 

Glauber's  salt;  it  is  a  powerful  purgative;  average  dose, 
16  Gm.  (240  grains). 

Describe  the  therapeutic  uses  of  sodium  chloride. 

A  bath  may  be  made  more  stimulating  for  debilitated 
patients  by  the  addition  of  a  few  ounces  of  salt  to  the  water. 
An  enema  containing  one  or  two  tablespoonfuls  of  salt  to  the 
pint  of  water  is  sometimes  used  effectively  against  thread- 
worms. The  subcutaneous  or  intravenous  injection  of  a 
three-tenth  per  cent,  solution  of  sodium  chloride  has  proven 
of  marked  benefit  in  cholera,  uremia  and  acute  anemia  from 
hemorrhages. 

State  the  composition  and  therapeutic  uses  of  pulvis 
jalapae  compositus. 

Compound  powder  of  jalap  contains  of  jalap  35  parts,  of 
potassium  bitartrate  65  parts,  rubbed  together  until  thor- 
oughly mixed.  It  is  much  employed  to  produce  free  watery 
evacuations  in  ascites  and  anasarca.  Since  it  is  nearly  taste- 
less, it  is  a  useful  cathartic  for  children. 

What  is  the  physiologic  action  of  camphor  in  medicinal 
doses  on  (a)  the  skin,  (b)  the  circulation? 

(a)  Rubefacient;  (h)  increases  the  pulse-rate  and  raises 
arterial  tension. 


THERAPEUTICS  AND  MATERIA  MEDICA.      325 

Describe  the  forms  of  poisoning  by  ergot. 

There  are  two  forms,  the  acute  ergotism  and  chronic  ergot- 
ism. The  symptoms  of  the  acute  form  are  nausea,  vomiting, 
colic,  difficult  micturition,  and  purging.  The  drug  slows  the 
heart,  raises  arterial  tension,  dilates  the  pupil,  and  produces 
vertigo.  It  stimulates  the  contraction  of  unstriped  muscle 
fiber,  especially  affecting  the  sphincters  and  uterus.  In  very 
large  doses  it  produces  cerebral  and  spinal  anemia  and  violent 
convulsions.  There  are  two  varieties  of  chronic  ergot 
poisoning,  the  convulsive  and  the  gangrenous.  The  convul- 
sions are  tetanoid  spasms  of  the  flexor  muscles,  the  uterus,  the 
intestinal  fibers  and  muscles  of  respiration,  ending  in  coma 
and  death  by  asphyxia.  The  gangrenous  form  begins  with 
coldness  and  numbness  of  the  limbs,  formication  of  the  skin, 
loss  of  sensibility  and  abolishment  of  the  special  senses,  bullae 
of  blood  and  ichor,  followed  by  dry  or  moist  gangrene  of  the 
lower  extremities,  buttocks  and  other  parts,  epileptiform  con- 
vulsions, coma  and  death. 

In  what  pathologic  condition  is  veratrum  viride  useful? 

Locally,  veratrum  is  of  value  in  neuralgia.  Internally  the 
drug  is  advised  by  some  in  the  early  stages  of  sthenic  pneu- 
monia and  in  puerperal  eclampsia. 

Mention  the  therapeutic  uses  of  phenacetine. 

It  is  antipyretic,  analgesic,  and  liypnotic.  It  is  useful  in 
whooping-cough  and  in  rheumatic  and  other  fevers. 

Give  the  name  of  the  alkaloid  of  Calabar  and  state  its 
dose. 

I*liysostigiiiine  (or  eserine).  The  dose  of  the  sulphate  is 
0.001  Om.  (V,,  grain). 

Mention  three  vegetable  emmenagogues  and  state  the 
dose  of  each. 

Ergot,  the  dose  of  the  fluid  extract  is  2  Ce.  (30  minims)  ; 
.savin,  the  dose  of  the  fluid  extract  is  0.3  Cc.  (5  minims)  ; 
tansy,  the  dose  of  the  oil  is  1  to  3  drops. 


326      THERAPEUTICS  AND  MATERIA  MEDICA. 

Define  therapeutic  incompatibility,  chemical  incompati= 
bility. 

Therapeutic  incompatibility  arises  when  two  agents  are 
administered  together  which  oppose  each  other  in  their  physi- 
ologic actions.  Chemical  incompatibility  is  due  to  the  union 
of  two  or  more  substances  in  combination  whereby  new  com- 
pounds result  that  are  injurious  in  their  action  in  the  body. 

Write  a  prescription  containing  dilute  hydrochloric  acid, 
syrup    of   wild    cherrj^   and    camphor   water   for   a    cough. 
Write  on  this  prescription  the  dose  for  an  adult. 
Jan.  1,  1910.  Mr.  John  Smith. 

R     Acidi  bydrochlorid  dil f 5  v 

Aquae  camphora? f  §  i 

Syr.  Pruni  virginianae  q.  s.  ad   f  §  iv 

M.  Sig.  — Teaspoonful  every  four  hours. 

Wm.  Jones,  M.  D. 

State  the  dose  of  (a)  fluid  extract  of  belladonna,  (b) 
extract  of  conium. 

(a)  0.05  Cc.  (1  minim),     (b)  0.2  Cc.  (3  minims). 

In  what  pathologic  conditions  is  uve  ursae  used? 

Uva  ursEe  is  employed  as  an  antiseptic  and  stimulating  diu- 
retic in  chronic  inflammatory  affections  of  the  genito-urinary 
tract,  such  as  pyelitis,  cystitis,  and  urethritis. 

State  the  name  and  the  dose  of  each  of  five  official 
preparations  of  opium. 

Opii  pulvis,  0.065  Gm.  (1  grain)  ;  extract  of  opium,  0.030 
Gm.  (1/^  grain)  ;  tincture  of  opium,  0.5  Cc.  (8  minims)  ;  cam- 
phorated tincture  of  opium  (paregoric),  8  Cc.  (2  fluid- 
drachms)  ;  wine  of  opium,  0.5  Cc.  (8  minims). 

In  what  diseases  are  preparations  of  arsenic  useful? 

Locally,  arsenic  is  useful  in  lupus  and  epithelioma.  It  is 
a  valuable  alterative  in  diabetes,  chronic  rheumatism,  phthisis 
and  asthma.  In  malaria  it  ranks  next  to  quinine;  in  the 
simple  chorea  of  childhood  it  is  almost  a  specific.  It  is  of 
great  value  in  anemic  conditions. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      327 

State  the  name  and  dose  of  a  drug  belonging  to  each  of 
the  following  classes:  (a)  emetics,  (b)  diuretics,  (c)  dia= 
phoretics,  (d)  cathartics. 

(a)  Ipecac,  the  emetic  dose  of  the  fluid  extract  is  1  Cc. 
(15  minims)  ;  (b)  digitalis,  the  dose  of  the  infusion  is  8  Cc. 
(2  fluiddrachms)  ;  (e)  pilocarpus,  dose  of  fluid  extract  is  2 
Cc.  (30  minims)  ;  (d)  jalap,  the  dose  of  the  compound  jalap 
powder  is  2  Gm.  (30  grains). 

State  the  name  and  the  alterative  dose  of  a  preparation 
of  mercury  capable  of  producing  acute  poisoning.  Men= 
tion  the  chemical  antidote  for  this  preparation. 

Bichloride  of  mercury;  dose,  0.003  Gm.  (V20  grain).  In 
cases  of  poisoning  by  corrosive  sublimate  the  stomach  should 
he  evacuated,  the  body  temperature  maintained,  and  egg  al- 
bumin given  in  large  quantities  as  an  antidote. 

How  should  asthma  of  cardiac  origin  be  treated? 

The  term  cardiac  asthma  is  applied  to  any  shortness  of 
breath  which  is  the  result  of  deranged  cardiac  action.  The 
treatment  is,  of  course,  the  treatment  of  the  diseases  which 
are  responsible  for  it.  Rest  in  bed  is  most  important.  The 
•cardiac  condition  may  indicate  the  need  of  digitalis  if,  for 
instance,  mitral  regurgitation  exists  with  loss  of  compensa- 
tion ;  strychnine  should  be  given  if  the  heart  muscle  is  weak ; 
citro-glycerine  may  be  given  in  the  early  stages  of  arterial 
.sclerosis;  morphine  and  atropine  are  used  for  the  paroxyms 
that  occur.  The  particular  treatment  will  depend  upon  the 
condition  of  the  circulation. 

Outline  the  treatment  of  uremia. 

The  name  uremia  is  applied  to  a  group  of  symptoms  result- 
ing from  the  retention  in  the  blood  of  toxic  materials  which 
should  have  been  eliminated  by  the  kidneys.  Sweating  should 
"be  encouraged  by  the  use  of  hot-air  or  vapor  baths.  Cath- 
arsis should  be  induced  by  croton  oil  in  one-drop  doses  or 
by  elaterium  in  %  grain  doses.  The  renal  engorgement  may 
be  relieved  by  a  dry  or  wet  cup  to  the  loins.     Venesection  is 


328      THERAPEUTICS  AND  MATERIA  ME  DIG  A. 

indicated  if  the  patient  is  robust  and  the  pulse  is  strong.  If 
the  pulse  is  weak,  heart  stimulants  should  be  administered. 
If  convulsions  occur,  30  to  40-grain  doses  of  chloral  may  be 
given  by  the  rectum,  or  nitrite  of  amyl  inhaled. 

Describe  the  treatment  of  apoplexy  due  to  cerebral 
hemorrhage. 

During  the  attack  the  head  and  shoulders  should  be  slightly 
elevated  and  an  ice-bag  applied  to  the  head.  Prompt  cath- 
arsis should  be  produced  by  croton  oil,  in  a  little  glycerin^ 
placed  on  the  back  of  the  tongue.  If  the  pulse  'be  strong^ 
bleeding  is  indicated;  if  the  pulse  is  feeble,  hypodermie 
injection  of  such  stimulants  as  strychnine  should  be  em- 
ployed. Bed  sores  must  be  prevented  by  frequently  chang- 
ing the  patient's  position  and  sponging  with  alcohol  the 
parts  exposed  to  pressure.  During  convalesence  those  pre- 
disposed to  such  attacks  should  lead  a  quiet  life  and  avoid 
excitement.  Iodide  of  potash  should  be  administered  over  a 
long  period.  After  the  primary  rigidity  has  appeared  in  the 
affected  muscles  galvanism  and  massage  may  assist  in  restor- 
ing lost  functions. 

State  the  official  name  and  the  minimum  poisoning  dose 
of  (a)  strychnine  sulphate,  (b)  morphine  sulphate,  (c) 
chloral.     State  the  antidote  for  each. 

(a)  StryehninaB  sulphas.  The  fatal  dose  of  strychnine- 
sulphate  is  placed  by  Taylor  at  i/o  to  2  grains  for  an  adult, 
but  recovery  has  taken  place  after  much  larger  doses.  The 
antidotes  are  chloral  hydrate,  tannic  acid  and  animal  char- 
coal, (b)  Morphinae  sulphas.  Toxic  dose  depends  on  per- 
sonal susceptibility;  %  grain  of  morphine  sulphate  has  killed 
an  adult.  Potassium  permanganate  is  the  best  antidote  if 
the  morphine  is  in  the  stomach ;  black  coffee  and  atropine  are 
of  value,  (c)  Chloral  hydrate  has  caused  death  in  several  in- 
stances by  a  30-grain  dose.    Atropine  is  its  antidote. 

Write  a  prescription  containing  the  tincture  of  the  chlor=^ 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      329 

ide  of  iron  and  the  chlorate  of  potash,  with  the  proper  dose 
for  a  child  four  years  old. 

R     Potassii  chloratis gr.  xvi 

Tincturse  ferri  chloridi f  3  iss 

Ext.  glycerrhizae 3  i 

Aquse,  q.  s.  ad f  §  iv 

Sig. — A  leaspoonful  in  water  every  tliree  hours. 

.John  Jonk.s,  M.  D. 

Criticize  the  following  prescription: 

Tr.  guaiac t"§  i 

Aq.  cinnamon f  §  ii 

Sig. — A  teaspoonful  every  four  hours. 

Dr.  J. 

This  is  an  example  of  pharmaceutical  incompatibility.  An 
alcoholic  tincture  should  not  be  prescribed  with  aqueous  solu- 
tions, nor  should  resinous  tinctures  be  combined  with  aqueous 
solutions. 

What  is  the  source  of  carbo  ligni?  What  are  the  thera= 
peutic  uses  of  carbo  ligni? 

Carbo  ligni  is  charcoal  derived  from  soft  wood.  It  is  em- 
ployed as  an  absorbent  of  foul  gases  and  as  a  deodorant  and 
disinfectant.  Internally  it  is  useful  in  affections  of  the  gastro- 
intestinal tract  associated  with  hyperacidity  and  tlatulent 
distension. 

Give  the  dose  of  (a)  caffeine,  (b)  wine  of  ipecac. 

(a)  0.065  Gm.  (1  grain);  (b)   1  Cc.  (15  minims). 

What  are  the  therapeutic  uses  of  convallaria  majalis? 

Lily-of-the-valley  possesses  actions  analogous  to  digitalis, 
strengthening  the  heart  and  increasing  the  flow  of  urine;  it 
does  not  disturb  the  slomaeh  and  is  iiol  cumulative  in  its 
effects. 

Define  a  general  anesthetic.  Mention  three  general 
anesthetics  in  common  use. 

A  general  anestlietic  is  a  drug  which  when  inhaled  suffi- 
ciently  produces  complete  unconsciousness  and  lo.ss  of  sen- 


330      THERAPEUTICS  AND  MATERIA  MEDIGA. 

sation,  also  lessened  motor  power.  The  general  anesthetics 
mostly  belong  to  the  alcohols  and  ethers.  Ether,  chloroform 
and  nitrous  oxide  are  three  examples  of  such  drugs. 

Mention  three  principal  salts  of  potassium  used  in  niedi= 
cine  and  give  the  dose  of  each. 

Potassium  bromide,  dose  1  Gm.  (15  grains)  ;  potassium 
acetate,  dose  2  Gm.  (30  grains)  ;  potassium  bicarbonate,  dose 
2  Gm.  (30  grains). 

Of  what  is  duboisine  an  alkaloid?  What  are  the  physio= 
logic  effects  of  duboisine? 

Duboisine  is  the  alkaloid  of  duboisia;  it  is  believed  to  be 
identical  with  hyoscyamine,  and  strongly  resembles  atropine. 
It  is  a  prompt  mydriatic.  In  moderate  doses  it  induces  quiet 
and  refreshing  sleep,  and  is  not  dangerous.  When  given  in 
large  doses  it  may  produce  vertigo,  nausea  or  syncope.  It  is 
less  irritating  to  mucous  membranes  than  atropine. 

What  are  the  therapeutic  uses  of  nitro=gIycerin?  By 
what  other  names  is  nitro=glycerin  known? 

Nitro-glycerin  is  also  known  as  glonoin  and  trinitrin  and 
glyceryl  trinitris.  It  is  valuable  in  certain  forms  of  cardiac 
diseases,  especially  in  sudden  heart  failure,  angina  pectoris 
and  fatty  degeneration  of  the  heart.  It  relieves  the  high 
arterial  tension  and  the  dyspnea  of  chronic  nephritis. 

Define  materia  medica;  therapeutics. 

Materia  medica  treats  of  the  substances  used  as  medicines 
and  describes  their  origin,  composition,  chemical  properties, 
modes  of  preparation  and  administration,  also  their  physio- 
logic and  toxicologic  actions.  Therapeutics  comprises  all  the 
science  and  art  of  healing,  including  the  use  of  medicines  and 
all  other  agents  given  with  the  object  of  curing  disease. 

What  are  the  therapeutic  uses  of  sulphur? 

Externally  it  is  of  value  as  a  stimulant  and  parasiticide  in 
diseases  of  the  skin  of  chronic  type.  Internally  it  is  a  mild 
laxative.  It  is  of  use  both  internally  and  externally  in 
chronic  articular  rheumatism. 


THERAFEUTICS  AND  MATERIA  MEDICA.      331 

Outline  the  general  treatment  of  acute  articular  rheu= 
matism.  Write  a  prescription  containing  at  least  two 
ingredients  for  an  adult  to  relieve  pain  in  acute  articular 
rheumatism. 

Rest  in  bed  is  essential.  The  joints  should  be  wrapped  in 
cotton-wool.  The  nourishment  should  consist  of  milk,  beef 
tea,  broths  and  gruel.  The  free  use  of  lemonade  or  mineral 
waters  is  advisable.  The  best  remedies  are  the  salicylates 
and  the  alkaline  salts  of  potassium.  The  following  is  a  use- 
ful combination : 

R     Sodii  salicylat 5  ii 

Potass,  citrat. 3  iii 

(ilycerini. 

Tinct.  cardamom,  comp aa  f  §  ss 

Aquae,  q.  s.  ad. f  §  v     ^^. 

Sig. — A  tablespoonful  every  two  hours. 

What  are  the  therapeutic  uses  of  strophanthus?  Men= 
tion  the  dose  of  the  tincture  of  strophanthus. 

Strophanthus  is  a  valuable  cardiac  tonic,  and  may  be  em- 
ployed in  the  class  of  cases  in  which  digitalis  is  indicated. 
The  dose  of  the  tincture  is  0.5  Cc.  (8  minims). 

Define  official  preparations  as  applied  to  preparations  of 
medicinal  agents. 

All  of  those  drugs  which  have  gained  entrance  to  the  Phar- 
macopcfiia  are  termed  official  preparations. 

What  are  the  therapeutic  uses  of  cardamom? 

It  is  used  as  an  agreeable  aromatic  for  disguising  the  taste 
•of  other  drugs  and  as  a  carminative. 

Describe  gelsemium?  State  the  dose  of  the  preparations 
of  gelsemium. 

Yellow  jasmine  is  the  rhizome  and  roots  of  gelsemium  sem- 
pervirens.  a  climbing  plant  of  the  natural  order  Loganiaceae. 
with  showy  yellow  flowers.  It  grows  in  the  forests  of  the 
southern  United  States.  It  contains  a  volatile  oil,  a  resin 
and  an  alkaloid,  gelsemine,  in  combination  with  golsemic  acid. 


332      rHERAPEVTICS  AND  MATERIA  MEDICA. 

Preparations  are  the  fluid  extract,  dose  0.05  Cc.  (1  minim)  ; 
the  tincture,  dose  0.5  Cc.  (8  minims).  Gelsemium  itself  is 
given  in  dose  of  0.065  Gm.  (1  grain). 

Mention  the  therapeutic  uses  of  iodine. 

Iodine  is  a  useful  counter-irritant.  Internally  it  is  used 
chiefly  for  its  alterative  effect.  In  the  form  of  Lugol's  solu- 
tion (2  or  3  drops)  it  will  sometimes  control  obstinate  vom- 
iting. 

State  the  physiologic  effects  of  physostigma  on  the  res= 
piration,  the  heart  and  the  pupil  of  the  eye. 

Small  doses  do  not  affect  the  circulation  or  respiration,  but 
toxic  doses  kill  by  paralyzing  the  respiratory  center.  The 
arterial  pressure  is  raised  by  the  drug  stimulating  the  heart 
or  its  contained  ganglia,  and  probably  also  by  stimulating  the 
vasomotor  center.  Toxic  doses  paralyze  the  heart.  Physo- 
stigmine  powerfully  contracts  the  pupil.  This  results  from 
stimulation  of  the  peripheral  fibers  of  the  oculo-motor  nerve 
and  from  paralysis  of  the  peripheral  filaments  of  the  sympa- 
thetic nerve. 

Describe  the  physiologic  action  of  phosphorus. 

In  small  doses  phosphorus  stimulates  the  brain  and  circu- 
lation, the  functions  of  the  stomach  and  the  genital  organs 
and  the  growth  of  bones.  It  aids  digestion  by  irritating  the 
end  organs  of  the  gastric  nerve,  but  produces  eructations  of 
hydrogen  phosphide. 

Outline  the  therapeutic  uses  of  atropine. 

Atropine  is  used  in  poisoning  by  opium,  physostigma  and 
hydrocyanic  acid.  In  ptyalism  from  mercury,  pregnancy, 
etc.,  in  the  sweats  of  phthisis,  in  sudden  cardiac  failure,  and 
as  a  mydriatic.  It  is  very  useful  in  lead-poisoning,  combined 
with  potassium  iodide..  It  is  useful  as  hemostatic  in  profuse 
metrorrhagia  after  abortion,  in  metrorrhagia  of  obscure 
origin,  and  in  the  hemoptysis  of  phthisis. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      333 

Define  sialagogue.  Give  an  example  of  (a)  topical  siala^ 
gogue,  (b)  general  sialagogue. 

Sialagogues  are  agents  which  increase  the  secretion  and 
flow  of  saliva  and  buccal  mucus.  Topical  sialagogues  act  by 
reflex  stimulation,  as  tobacco  and  mustard.  General  siala- 
gogues act  through  their  influence  on  the  glands  or  their 
secretory  nerves,  as  pilocarpine  and  the  mercurials. 

For  what  pathologic  conditions  is  camphor  used? 

Camphor  may  be  employed  in  diarrhea,  cholera,  vomiting, 
cardiac  depression,  nervousness  and  nervous  headache,  the  in- 
fectious fevers,  dysmenorrhea,  after-pains,  and  catarrhal  con- 
ditions. Locally  it  is  of  use  wherever  counter-irritation  or  a 
local  anodyne  is  required. 

Give  the  official  name  and  the  composition  of  (a)  Fow= 
ler's  solution,  (b)  Donovan's  solution. 

Solution  of  potassium  arsenite  is  a  1  per  cent,  solution  pre- 
pared by  boiling  together  arsenous  acid  1,  potassium  bicar- 
bonate 2.  compound  tincture  of  lavender  3,  and  distilled 
water  to  100  parts.  The  solution  of  arsenous  and  mercuric 
iodides  (Donovan's  solution)  contains  arsenous  iodide  and 
mercuric  iodide,  of  each  1  part  in  100  of  distilled  water. 

State  the  dose  of  (a)  spirit  of  nitro=glycerin,  (b)  wine 
of  colchicum  (sem.),  (c)  extract  of  colocynth. 

(a)  0.05  Cc.  (1  minim)  ;  (b)  2  Cc.  (30  minims)  ;  (e)  0.030 
Gm.  (1/2  grain). 

Describe  the  therapeutic  applications  of  sulphate  of 
copper. 

It  is  a  prompt  and  efficient  emetic,  and  is  so  used  in  croup 
and  narcotic  poisoning.  In  phosphorus  poisoning  it  forms  a 
comparatively  insoluble  phosphide  of  copper,  besides  produc- 
ing emesis.  It  is  of  value  combined  with  opium  in  acute 
diarrhea  and  chronic  dysentery.  Ix)cally  it  is  employed  in 
throat  aff'ections,  gonorrhea,  granular  lids,  corneal  ulcers,  and 
chronic  inflammation  of  mucous  membranes. 


334      THERAPEUTICS  AND  MATERIA  MEDICA. 

Mention  (a)  a  hydrogogue,  (b)  a  cholagogue.  State  the 
dose  of  each. 

(a)  Elaterium,  the  active  principle,  elaterin,  is  given  in 
doses  of  0.005  Gm.  C/^o  grain)  ;  (b)  podophyllum,  dose  0.500 
Gm.  (71/2  grains). 

Mention  four  remedies  used  to  control  vomiting  and 
state  the  dose  of  each. 

Cerium  oxalate,  0.065  Gm.  (1  grain)  ;  subnitrate  of  bis- 
muth, 0.500  Gm.  (71/^  grains)  ;  cocaine  hydrochloride,  0.030 
Gm.  (%  gi'ain)  ;  acid  carbolic,  0.065  Gm.  (1  grain). 

Write  a  compound  prescription  for  an  adult  suffering 
from  insomnia. 

Jan.  1,  1910.  Mr.  John  Smith.. 

R     Potassii  bromidi 5  iv 

Chloralis  hydratis 3  iii 

Tincturae  assafoetidse f  3  iv 

Sy  rupi f  3  vi 

Aquse,  q.  s.  ad. f  §  vi 

M.  Sig. — Tablespoonful  every  two  hours  until  sleep  is  induced. 

Jos.  Jones,  M.  D. 

What  are  the  uses  of  apomorphine? 

In  narcotic  poisoning,  such  as  from  opium  or  alcohol,  apo- 
morphine is  a  valuable  emetic.  When  the  circulation  is  weak 
it  must  be  given  cautiously.  It  is  of  service  as  an  expectorant 
in  the  dry  stage  of  acute  bronchitis  and  in  chronic  bronchitis 
when  the  expectoration  is  viscid  and  scanty.  The  emetic  dose 
of  apomorphine  hydrochloric  is  0.005  Gm.  (Vio  grain)  in 
alcohol.  As  an  expectorant  by  the  mouth  the  dose  is  0,002 
Gm.  (Vso  grain). 

State  the  effects  of  amyl  nitrite  on  the  vascular  system. 

The  inhalation  of  nitrite  of  amyl  is  speedily  followed  by 
flushing  of  the  face,  fulness  in  the  head,  quickening  of  the 
pulse  and  a  fall  of  the  blood-pressure.  The  flushing  is  due 
to  dilatation  of  the  arterioles,  brought  about  partly  by  de- 
pression of  the  vasomotor  centers  and  partly  by  direct  action 
on  the  blood-vessel  walls.     The  quickening  of  the  pulse  re- 


THEBAPEUTICIS  AND  MATERIA  MEDICA.      335 

suits  from  a  depression  of  the  cardiac  inhibitory  centers  in 
the  medulla.  The  fall  of  blood-pressure  is  mainly  due  to  dila- 
tation of  the  vessels.  Upon  the  heart  the  drug  acts  primarily 
as  a  stimulant,  but  in  large  amounts  it  soon  acts  as  a  cardiac 
depressant. 

Describe  asafetida  and  outline  its  physiologic  effects. 

Asafetida  is  a  gum-resin  obtained  by  incision  from  the 
living  root  of  ferula  fetida,  a  perennial  herb  of  the  nautral 
order  UmbellifertE,  native  of  Persia  and  Afghanistan.  Its 
principal  constituent  is  a  sulphuretted  volatile  oil;  it  also 
contains  a  gum  and  a  resin.  It  is  a  powerful  anti-spasmodic, 
a  stimulant  to  the  brain  and  nervous  system,  a  stimulant  ex- 
pectorant; also  tonic,  laxative,  diuretic,  diaphoretic,  emmena- 
gogue,  aphrodisiac  and  anthelmintic  in  action. 

State  the  effect  of  the  bromides  on  the  respiration  and 
on  the  action  of  the  heart.  What  effect  is  the  long  con= 
tinued  use  of  the  bromides  liable  to  produce  on  the  mental 
faculties? 

The  bromides  reduce  the  number  of  the  respirations,  and 
the  heart's  action  and  force,  and  lower  the  arterial  tension. 
The  continued  use  lessens  the  activity  of  the  brain-cells,  pro- 
ducing weakness  of  mind  and  somnolence. 

In  what  diseases  is  conium  used? 

It  is  especially  indicated  in  diseases  characterized  by  exces- 
sive motor  activity.  It  is  useful  in  chorea,  paralysis  agitans, 
in  acute  mania,  and  delirium  tremens ;  it  is  also  employed  n 
tetanus,  asthma,  whooping-cough,  and  other  spasmodic  affec- 
tions. 

Define  diaphoresis.  Mention  three  diaphoretics  and 
state  the  dose  of  each. 

Diaphoresis  is  a  condition  of  sweating.  Aconite,  veratrum 
viride,  and  the  salicylate  of  sodium.  The  dose  of  aconitine  is. 
0.00015  Gm.  (V400  grain).  The  tincture  of  veratrum,  1  Cc. 
(15  minims).     Salicylate  of  sodium,  1  Gm.  (15  grains). 


336      THERAPEUTICS  AND  MATERIA  MEDICA. 

Mention  ten  drugs,  the  use  of  any  one  of  which  may 
cause  skin  eruption. 

Aconite,  antimony,  antipyrine,  atropine,  quinine,  tar,  tur- 
pentine, salicylic  acid,  mercury,  opium. 

Write  a  prescription  containing  a  stomachic  to  be  used 
in  alcoholism. 

R     Tinct.  Gentianse  Co f  §  iv 

Tinct.  Nucis  Vomicae f^^ii 

M.  Sig. — Teaspoonful  before  meals. 

What  is  the  alkaloid  of  hyoscyamus?  What  is  the  dose 
of  hyoscine  hydrobromide  for  hypodermic  use? 

It  contains  an  alkaloid,  hyoscyamine.  The  dose  of  hyos- 
cine hydrobromide  for  hypodermic  use  is  0.0005  Gm.  (V128 
grain). 

In  what  form  is  iodine  most  frequently  administered  in= 
ternally?     What  is  the  antidote  for  free  iodine? 

Potassium  iodide.  Starch  is  the  antidote  to  free  iodine,  but 
the  stomach  must  be  immediately  evacuated,  as  the  iodide  of 
starch  is  not  inactive. 

Mention  three  commonly  used  myotics. 

Eserine  is  the  only  myotic  generally  employed  in  ophthal- 
mic practice.  Opium  and  pilocarpine  are  two  other  drugs 
possessing  myotic  effects. 

State  the  effects  of  alcohol  and  strychnine  on  the  arte= 
rioles. 

Alcohol  causes  a  dilatation  of  the  arterioles,  while  strych- 
nine contracts  the  arterioles,  except  in  very  large  doses,  when 
it  produces  relaxation  of  the  smaller  vessels. 

Describe  the  symptoms  and  give  the  treatment  of  gas^ 
tro=duodenitis. 

The  symptoms  of  gastro-duodenitis  partake  of  gastritis 
with  an  enteritis  added,  fever,  gastric  pain  and  vomiting,  in 
addition  to  which  there  may  be  colic  and  diarrhea.  Smple 
catarrhal  jaundice  will  result  from  an  extension  of  a  gastro- 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      337 

•duodenitis  into  the  common  duct.  The  general  symptoms  of 
this  condition  are  jaundice,  loss  of  appetite,  nausea,  vomiting, 
^  sense  of  fulness  and  constipation  or  irregular  action  of  the 
bowels:  there  may  also  be  slight  fever.  The  treatment  con- 
sists in  saline  aperients,  which  reduce  the  catarrhal  inflam- 
mation; and  second,  the  use  of  such  foods  as  do  not  require 
the  bile  to  facilitate  digestion.  Skimmed  milk,  animal  broths 
•and  egg  albumin  and  copious  drinking  of  water  are  advised. 

Mention  the  chief  alkaloids  and  the  therapeutic  class  of 
belladonna  and  of  Calabar  bean. 

Belladonna  contains  two  alkaloids,  the  official  atropine  and 
hyoscyamine.  Belladonna  is  a  delirifacient.  Calabar  bean 
contains  physostigmine   (eserine).     It  is  a  depresso-motor. 

Mention  a  soluble  salt  of  lead.  To  what  therapeutic 
class  does  bismuth  subnitrate  belong? 

Lead  acetate.  Bismuth  subnitrate  is  classed  with  astrin- 
gents. 

What  is  the  physiologic  action  of  Indian  hemp? 

Cannabis  indica.  Indian  hemp,  produces  in  full  doses  a  con- 
dition of  mental  exhilaration  associated  with  hallucinations 
and  disordered  consciousness  of  time,  locality  and  pereonality. 
This  stage  of  excitement  finally  gives  way  to  sleep,  which  may 
last  for  several  hours.  Sensation  is 'perverted  and  benumbed. 
and  before  sleep  is  induced  there  is  often  more  or  less  general 
anesthesia.  The  drug  has  little  influence  upon  circulation 
and  respiration. 

What  is  the  physiologic  action  of  veratrum  viride  "on  the 
•circulation? 

It  lessens  greatly  the  force  and  rate  of  cardiac  pulsation 
-and  reduces  arterial  tension  by  depression  of  the  vasomotor 
•center  and  of  the  heart  itself. 

Give  the  physiologic  action  of  senna  and  state  what  part 
of  it  is  used  in  medicine.  Where  does  senna  grow  most 
Jibundantly? 

The  leaflets  of  Cassia  acutifolia  and  of  Cassia  angustifolia; 
22 


338      THERAPEUTICS  AND  MATERIA  MEDIC  A. 

the  former  grows  in  Egypt  and  the  latter  in  southern  India. 
Senna  is  a  brisk  cathartic,  producing  in  three  or  four  hours 
after  its  ingestion  copious  watery  stools.  It  acts  by  increas- 
ing both  peristalsis  and  the  intestinal  secretion.  It  is  ab- 
sorbed by  the  circulation. 

Describe  bromism  and  state  how  it  is  produced. 

Bromism  is  produced  by  the  continuous  administration  of 
bromides.  The  condition  is  characterized  by  anemia,  fetor 
of  the  breath,  gastric  disturbance,  diminution  of  the  reflexes, 
unsteady  gait,  impairment  of  tactile  sensibility,  aboliton  of 
sexual  function,  mental  depression,  failure  of  memory,  som- 
nolence, and  a  general  eruption  of  acne. 

What  are  the  therapeutic  uses  of  sodium  salicylate? 

It  is  of  value  as  an  antipyretic,  as  an  anti-rheumatic  and 
anti-neuralgic.  It  is  of  greatest  service  in  pleurisy  with 
serous  effusion,  and  is  often  useful  in  diabetes.  When  given 
early  it  will  often  abort  tonsilitis.  It  is  of  service  as  a  gastro- 
intestinal disinfectant. 

Give  the  dose  of  pilocarpine. 

The  dose  of  pilocarpine  hydrochloride  is  0.01  Gm.  (y^ 
grain). 

Describe  the  therapeutic  uses  of  hydrochloric  acid. 

It  is  employed  internally  in  the  treatment  of  dyspepsia 
associated  with  subacidity.  It  is  useful  as  a  refrigerant  and 
digestant  in  the  continued  fevers.  In  conjunction  with 
strychnia  it  is  of  value  in  intestinal  indigestion.  The  strong 
acid  is  also  an  escharotic. 

What  are  the  principal  uses  of  calcium  chloride?  To 
which  ingredient  does  it  owe  its  energy? 

Calcium  chloride  is  of  value  as  an  internal  remedy  in  the 
various  manifestations  of  the  strumous  diathesis  and  to  arrest 
bleeding.  It  often  causes  the  resolution  of  glandular  enlarge- 
ment, and  is  of  value  in  chorea,  lupus  and  eczema.  It  owes 
its  energy  to  the  calcium  contained. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      339 

What  are  the  symptoms  of  opium  poisoning? 

Unless  the  dose  has  been  very  large  there  is  at  first  a  stage 
of  excitement,  in  which  the  imagination  is  stimulated  and 
the  feelings  exalted.  This  stage  is  soon  followed  by  depres- 
sion; the  patient  becomes  stupid  and  drowsy,  and  finally  falls 
asleep.  The  sleep  deepens  into  coma,  the  pulse  becomes  slow 
and  full,  the  pupils  contracted,  the  respiration  slow  and  heavy 
and  the  face  suft'used.  At  this  time  it  is  still  possible  to 
arouse  the  patient  by  a  loud  noise,  flagellation  or  shaking. 
In  the  third  stage  the  coma  becomes  absolute,  the  pulse  rapid 
and  feeble,  the  breathing  shallow  and  irregular,  the  skin 
moist,  the  muscles  relaxed,  the  pupils  dilated,  and  finally 
death  results  from  paralysis  of  the  respiration. 

Mention  the  remedy  which  will  arrest  the  secretion  of 
milk  and  state  how  it  should  be  employed. 

Camphor  used  locally  by  inunction  in  saturated  solution 
of  olive  oil  is  efficient  in  checking  the  secretion  of  milk,  as  is 
belladonna. 

Give  the  methods  and  the  therapy  of  cold  water  treat= 
ment  applied  externally. 

Cold  water  may  be  applied  in  the  form  of  cloths  saturated 
with  it,  by  sponging,  bathing  or  packing  with  ice.  The  cold 
bath  is  the  most  frequently  employed.  A  bath-tub  half  full 
of  water  at  70'^  F.  is  kept  in  readiness  at  the  bedside  of  the 
patient,  and  whenever  the  temperature  rises  above  102.4°  F. 
the  patient  is  wrapped  in  a  sheet  and  carefully  lifted  into  the 
tub.  While  in  the  bath  cold  affusions  should  be  applied  to  the 
head,  and  the  body  should  be  constantly  subjected  to  gentle 
friction  and  massage,  so  as  to  bring  new  relays  of  blood  to 
the  surface.  A  stimulant  is  often  necessary  to  counteract  the 
shock.  After  remaining  in  the  water  15  to  20  minutes  he  is 
placed  in  a  dry  sheet  and  covered  with  a  light  blanket. 

What  are  therapeutic  uses  of  alcohol? 

The  question  of  the  advisability  of  employing  alcohol  in 
medicine  has  given  rise  to  never-ending  controversy.     Many 


340      THERAPEUTICS  AND  MATERIA  MEDIC  A. 

give  it  a  high  place,  while  others  do  not  employ  it  at  all.  The 
external  and  local  use  of  alcohol  includes  many  applications 
of  its  antiseptic,  refrigerant  and  rubefacient  qualities.  In 
the  form  of  champagne  it  is  especially  valuable  in  controlling 
vomiting.  A  single  dose  of  whiskey  or  brandy  is  an  efficient 
combatant  of  fainting  or  of  collapse.  In  fevers  it  acts  as  an 
antipyretic,  a  food,  and  promotes  sleep.  It  is  well  to  with- 
hold it  until  the  first  sound  of  the  heart  becomes  feeble  and 
dull,  and  then  to  use  it  boldly.  It  is  of  especial  value  in  the 
treatment  of  pneumonia,  typhoid  fever  and  snake-bite. 

Mention  the  physiologic  effects  of  bryonia.  What  is  the 
dose  of  the  tincture  of  bryonia? 

Bryonia  is  a  pure  irritant,  setting  up  local  inflammation 
wherever  it  is  applied.  It  has  a  vesicant  action  on  the  skin, 
and  is  violently  irritant  to  the  serous  and  mucous  membranes. 
It  produces  cerebral  congestion,  with  frontal  headache  and 
vertigo.  It  is  a  drastic  purgative  and  a  powerful  diuretic. 
It  causes  in  full  dose  hepatic  and  renal  congestion,  vesical 
tenesmus,  and  depression  of  the  heart's  action.  The  dose  of 
the  tincture  is  5  drops  to  i/o  ounce. 

State  the  dose  of  aconitine. 

0.00015  Gm.  (V,,o  grain). 

Give  the  composition  and  state  the  uses  of  lotio  hydrar= 
gyri  flava. 

Yellow  wash  is  a  favorite  application  for  syphilitic  sores. 
It  is  prepared  by  adding  18  grains  of  corrosive  sublimate  to 
10  ounces  of  lime-water,  producing  the  yellow  oxide. 

Give  indications  for  the  internal  use  of  bichloride  of 
mercury.  State  the  dose  of  bichloride  of  mercury  for  in= 
ternal  use. 

It  is  of  value  in  anemia,  as  an  absorbent  in  diphtheria,  as 
a  general  alterative,  and  is  highly  prized  as  an  anti-syphilitic 
remedy  in "  the  secondary  and  tertiary  stages.  The  dose  is 
0.003  Gm.  (V20  grain). 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      341 

What  are  the  principal  therapeutic  uses  of  the  salts  of 
lead? 

Lead  salts  are  chiefly  used  as  astringents  and  hemostatics. 
The  acetate  is  an  efficient  internal  styptic.  The  nitrate  is  of 
value  locally  in  epithelioma  and  unhealthy  granulations.  The 
iodide  is  employed  locally  to  enlarged  lymphatic  glands  and 
in  chronic  skin  affections.  The  carbonate  is  only  used  exter- 
nally to  protect  irritated  surfaces,  such  as  intertrigo,  etc. 

Explain  the  constipating  action  of  opium. 

Opium  arrests  all  the  secretions  except  the  milk  and  the 
sweat,  and  retards  the  digestive  juices.  The  biliary  and  gly- 
cogenic functions  of  the  liver  are  affected  and  metabolism 
greatly  reduced.  Its  constipating  action  is  produced  chiefly 
by  stimulation  of  the  inhibitory  nerves  of  the  intestines 
through  the  splanchnics. 

Mention  the  symptoms  of  poisoning  by  phosphorus. 

Toxic  doses  of  phosphorus  produce,  after  the  lapse  of  a  few 
hours,  a  garlicky  taste  in  the  mouth,  thirst,  intense  abdominal 
pain,  obstinate  vomiting,  restlessness  and  prostration.  The 
ejected  materials  contain  mucus,  bile,  and  occasionally  dis- 
integrated blood,  and  are  luminous  in  the  dark.  At  the  end 
of  24  or  36  hours  the  symptoms  gradually  subside  and  the 
patient  feels  comparatively  comfortable,  but  soon  jaundice 
develops,  the  vomiting  and  pain  return,  the  liver  becomes 
enlarged  and  painful,  the  urine  contains  albumin,  bile,  hypo- 
phosphoric  acid  and  crystals  of  leucin  and  tyrosin.  The 
tongue  is  coated,  the  breath  offensive,  the  belly  distended,  the 
bowels  either  constipated  or  loose,  and  the  stools  clay-colored. 
Death  is  generally  preceded  by  grave  nervous  symptoms,  such 
as  headache,  delirium,  convulsions,  stupor  and  coma.  When 
recovery  follows,  convalescence  is  protracted. 

Write  a  prescription  containing  a  sedative  and  an  ex- 
pectorant for  a  bronchial  cough  in  a  three-year-old  child.s 
Jan.  1,  1910.  For  Wai.tkk  Smith. 

R     Tinctura  opii  camphoraUe gtt.  Ixiv 

Pota.ssii  citratis 3 "  i 

Synipi  pruni  virginianse,  q.  s.  ad f  5  '^' 

M.  Sisr. — Teaspoon ful  every  four  hours. 

Wm.  Joni->,  M.  1). 


342      THERAPEUTICS  AND  MATERIA  MEDICA. 

In  what  pathologic  condition  is  jaborandi  useful? 

It  is  of  use  in  dropsy,  especially  of  renal  origin,  in  uremia, 
inflammation  of  the  serous  membranes,  in  diabetes  insipidus, 
but  is  contra-indicated  when  the  heart's  action  is  weak.  It 
is  useful  in  the  form  of  a  lotion  for  alopecia. 

What  is  the  dose  of  carbolic  acid  for  internal  adminis- 
tration? 

Dose  0.065  Gm.  (1  grain),  well  diluted. 

What  is  the  common  name  of  lactucarium?  State  the 
physiologic  action  of  lactucarium. 

Lettuce.  Lactucarium  is  feebly  hynotic  and  somewhat 
sedative  and  diuretic.  The  syrup  is  a  good  vehicle  for  ex- 
pectorants and  anti-spasmodics. 

What  is  the  physiologic  action  of  colchicum? 

Emetic,  diuretic,  diaphoretic,  a  drastic  purgative  and  car- 
diac depressant,  gastro-intestinal  irritant.  In  small  doses  it 
is  an  emeto-cathartic. 

What  serious  results  may  ensue  from  indiscriminate  use 
of  acetanilide? 

A  toxic  dose  destroys  the  oxygen-carrying  function  of  the 
blood  and  forms  methemoglobin,  causes  fatty  degeneration 
of  the  heart,  liver  and  kidneys  in  animals  poisoned  by  it. 
When  administered  continually  or  in  too  large  dose  it  is  apt 
to  cause  subnormal  temperature,  cyanosis  and  collapse. 

What  is  cascara  sagrada?  State  the  dose  of  the  fluid 
extract  of  cascara  sagrada. 

It  is  the  bark  of  Rhamnus  purshiana,  California  buckthorn. 
The  dose  of  the  fluid  extract  is  1  Cc.  (15  minims). 

What  are  the  therapeutic  uses  of  tincture  of  capsicum 
internally  administered?  State  the  dose  of  the  tincture 
of  capsicum. 

It  is  employed  chiefly  as  a  stomachic  and  carminative.     A 


THERAPEUTICS  AND  MATERIA  MEDICA.      343 

weak  solution  of  the  tincture  is  also  a  much-used  gargle  in 
sore  throat  with  relaxed  uvula.  The  drug  is  especially  valu- 
able in  alcoholic  gastritis  and  obstinate  constipation.  The 
dose  of  the  tincture  is  0.5  Cc.  (8  minims). 

What  part  of  aconite  is  used  in  medicine?  What  is  the 
alkaloid  of  aconite? 

Aconite  is  derived  from  the  root  of  the  aconitum  napellus. 
Its  most  important  alkaloid  is  aconitine. 

Write  a  prescription  for  corrosive  sublimate  to  be  used 
as  a  parasiticide. 

Jan.  1,  1910.  For  John  Jones. 

Hydrargyri  bichloridi gr.  ii 

Unguenti  petrolati f  §  i 

M.  et  Sig. — I'se  locally.  John  Smith,  M.  D. 

How  is  liquor  ammonii  acetatis  prepared?  In  what 
conditions  is  this  preparation  useful? 

Spirit  of  Mindererus  is  prepared  by  neutralizing  dilute 
acetic  acid  with  ammonium  carbonate ;  it  should  be  freshly 
made,  as  it  soon  deteriorates.  It  is  an  active  diuretic  if  the 
body  be  cool,  and  a  diaphoretic  if  the  body  be  warm.  In 
wineglassful  doses  it  will  counteract  many  of  the  immediate 
effects  of  alcohol. 

What  is  the  common  name  of  staphisagria?  What  are 
the  therapeutic  uses  of  staphisagria? 

Staphisagria.  commonly  known  as  stavesacre,  is  a  violent 
emetic,  cathartic  and  parasiticide. 

Mention  the  preparations  of  ammonia.  What  effect  has 
ammonia  on  the  heart? 

The  official  preparations  are  aqua  ammoniae,  aqua  ammoniae 
fortior.  linimentum  ammonias,  spiritus  ammoniae,  spiritus  am- 
monia aromaticus.  Moderate  doses  of  ammonia  increa.se  the 
strength  and  rapidity  of  the  heart,  and  this  effect  is  produced 
bv  a  direct  stimulation  of  the  heart  and  its  accelerator  nerves. 


344      THERAPEUTICS  AND  MATERIA  MEDICA. 

Write  a  compound  prescription  for  an  adult  containg 
iron,  quinine  and  opium  in  pill  form  for  neuralgia. 

Jan.  1,  1910.  John  Smith.. 

R     Pul  veris  opii gr.  x 

Ferri  sulphatis  exsiccatae, 

Quininse  sulphatis aa  gr.  xx 

M.  et  fiant  in  pilulje  No.  20. 

Sig. — One  every  four  hours.  John  Jones,  M.  D. 

Define  tincture  and  spirits. 

Tinctures  are  alcoholic  solutions  of  medicinal  substanees.- 
Spirits  are  alcoholic  solutions  of  volatile  substances,  which 
may  be  solids,  liquids  or  gases.  Tinctures,  with  the  exception 
of  the  tincture  of  iodine,  are  made  from  non-volatile  bodies. 

Mention  three  drugs  used  to  accelerate  the  action  of  the 
heart  and  give  the  dose  of  some  preparation  of  each. 

Atropine;  dose  of  atropine  sulphate,  0.0004  Gm.  (Vieo 
grain).  Nitro-glycerin ;  dose  of  spirit,  0.05  Ce.  (1  minim). 
Ammonia;  dose  of  the  aromatic  spirits,  2  Cc.  (30  minims). 

Give  the  treatment  of  obstinate  hiccough. 

Rhythmic  traction  of  the  tongue  will  often  arrest  obstinate 
hiccough.  Ether  as  a  spray  to  the  epigastrium  for  ten  min- 
utes, then  to  the  site  of  the  phrenic  in  the  neck,  is  also  ad- 
vised. Morphine  hypodermatically,  either  alone  or  in  combi- 
nation with  atropine,  has  sometimes  proven  effective. 

What  is  the  physiologic  effect  of  cocaine  on  the  ocular 
conjunctiva,  the  pupil  of  the  eye  and  the  salivary  and 
sweat  glands. 

Cocaine  dropped  upon  the  conjunctiva  causes  dilatation  of 
the  pupil  and  profound  anesthesia  of  that  membrane;  it  also 
produces  partial  paralysis  of  accommodation,  slight  lachry- 
mation,  and  sometimes  temporary  ptosis.  It  lessens  the 
secretion  of  the  salivary  glands  and  the  sweat  glands. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      345 

Write  a  prescription  for  a  syphilitic  adult  containing 
corrosive  sublimate  and  iodide  of  potassium  in  solution. 

Jan.  1,  1910.  For  .John  Jones. 

R     Hydrargyri  chloridi  corrosivi gr.  i 

Potassii  iodidi 3  ii 

Tincturifi  gentianse  comp f§iii 

M.  et  Sig. — A  teaspoonful  thrice  daily  after  meals. 

John  Smith.  M.  D. 

What  are  the  therapeutic  uses  of  tar? 

Tar  is  used  as  a  stimulating  expectorant  and  as  a  stimulant 
to  the  skin  in  certain  chronic  inflammatory  diseases. 

What  are  the  physiologic  effects  and  therapeutic  uses  of 
chromic  acid? 

Chromic  acid  exerts  a  powerful  caustic  effect  upon  all  ani- 
mal tissue.  It  has  a  destructive  action  upon  micro-organisms, 
and  from  the  readiness  with  which  it  parts  with  its  oxygen  it 
rapidly  decomposes  organic  matter,  and  so  serves  as  a  disin- 
fectant. It  is  not  employed  internally.  It  is  a  useful  escha- 
rotic  for  destroying  corns,  warts,  syphilitic  vegetations,  and 
the  like. 

Give  the  source  and  state  the  uses  of  thymol. 

Thymol  is  obtained  from  the  volatile  oil  of  thyme  and  cer- 
tain other  volatile  oils.  Thymol  is  used  as  a  disinfectant  in 
the  form  of  a  wash,  as  an  ointment  in  chronic  skin  diseases, 
and  internally  as  an  efficient  antiseptic. 

What  is  the  dose  of  croton  oil  as  a  cathartic?  What  are 
the  contra=indications  to  its  use? 

The  dose  is  0.05  Cc.  (1  minim),  given  in  glycerin  or  olive 
oil.  It  is  contra-indicated  when  either  debility,  organic  ob- 
struction, or  inflammatory  conditions  of  the  stomach  or 
bowels  exist. 

What  are  the  physiologic  effects  and  therapeutic  uses  of 
cubebs? 

Cubebs  is  an  aromatic  stomachic  and  a  stimulant  diuretic 
in  small  or  medium  doses,  but  large  amounts  derange  digestion 


346      THEBAPEUTIC8  AND  MATERIA  MEDIC  A. 

and  may  act  as  a  gastro-intestinal  irritant.  Its  constituents 
are  eliminated  by  the  bronchial  -mucous  membranes,  the  skin 
and  the  kidneys,  stimulating  and  disinfecting  the  genito- 
urinary passages,  increasing  the  bronchial  mucus,  sweat  and 
urine,  and  frequently  causing  an  urticarial  or  vesicular  erup- 
tion. It  increases  the  action  of  the  heart  and  the  vascular 
system  and  promotes  the  menstrual  discharge.  Cubebs  is 
used  in  the  acute  stage  of  gonorrhea,  in  chronic  cystitis  and 
chronic  bronchitis.  It  is  applied  in  powder  form  in  hay 
fever,  chronic  nasal  catarrh  and  follicular  pharyngitis. 

Mention  the  therapeutic  uses  of  carbolic  acid  except  as 
an  antiseptic. 

It  is  used  as  a  caustic,  local  anesthetic,  as  an  anti-emetic 
and  carminative. 

What  is  the  treatment  of  scabies? 

Sulphur,  styrax  and  naphthol  are  efficient  local  applica- 
tions as  ointments. 

An  excellent  formula  is  the  following: 

Sulphur  sublimat. 3j 

Balsam  Peru vianse 3  ss 

Adipis § j 

M.  et  Sig. — Rub  in  thoroughly  twice  a  day. 

How  does  an  antagonist  differ  from  an  antidote? 

Antagonists  are  agents  which  oppose  each  other  in  their 
physiologic  action,  and  may  be  employed  against  each  other 
as  counter  poisons  to  neutralize  their  effects  upon  the  organ- 
ism. They  do  their  work  in  the  blood  and  tissues  after  ab- 
sorption, and  are  especially  available  against  poisons  admin- 
istered hypodermically,  in  which  case  antidotes  are  useless. 
Antidotes  affect  a  poison  so  as  to  remove  it  from  the  body  or 
alter  its  character  before  absorption,  and  thereby  prevent  its 
toxic  action  on  the  organism.  They  do  their  work  in  the  ali- 
mentary canal  or  in  the  respiratory  passages.     (Potter.) 

Name  and  describe  the  methods  of  introducing  medi= 
cines  into  the  circulation. 

Medicines  may  be  introduced  into  the  circulation  by  vari- 


THERAPEUTICS  AND  MATERIA  MEDICA.      347 

ous  routes,  including  the  mouth,  the  stomach,  the  rectum,  the 
respiratory  tract,  the  veins  and  arteries,  the  subcutaneous 
cellular  tissues,  and  the  skin.  Intravenous  medication  is  only- 
used  in  emergencies  where  immediate  action  is  desired. 
Saline  solution  is  the  usual  remedy  introduced  by  this  route. 
The  rectum  will  absorb  any  substances  applied  in  the  form 
of  enemata  or  suppositories.  The  hypodermic  method  is  the 
introduction  of  medicines  into  the  organism  by  injecting  them 
into  the  subcutaneous  tissue,  from  which  they  are  quickly 
absorbed  by  the  lymphatic  and  capillary  vessels.  The  respir- 
atory tract  admits  of  the  rapid  absorption  of  medicinal  sub- 
stances through  its  extensive  blood  supply,  especially  by  in- 
halation. The  stomach  is  the  most  convenient  organ  for  the 
absorption  of  medicine.  The  remedies  find  their  way  into  the 
current  of  the  circulation  through  the  walls  of  the  gastro- 
intestinal blood-vessels  and  the  lacteals. 

How  do  strophanthus  and  digitalis  differ  in  physiologic 
action? 

Compared  with  digitalis,  strophanthus  is  a  powerful  car- 
diac stimulant,  differing  from  digitalis  in  not  producing 
vasomotor  constriction  of  the  arterioles.  It  reduces  the  pulse, 
lowers  body  temperature  somewhat,  is  not  cumulative  in 
action,  and  does  not  cause  any  gastro-intestinal  disturbance. 
It  is  a  diuretic  by  direct  stimulation  of  the  renal  circulation, 
and  has  power  over  rigors  by  its  rapid  cardiac  action,  stop- 
ping them  and  preventing  their  recurrence. 

Mention  the  official  turpentines.  State  from  whence 
they  are  obtained. 

There  are  two  official  turpentines,  terebinthina,  a  concrete 
oleorsin  from  Pinus  palustris,  the  yellow  pine,  and  other 
species  of  Pinus,  natural  order  Coniferae;  Terebinthina  cana- 
densis, a  liquid  oleorsin  obtained  from  Abies  balsamje,  the 
balm  of  Gilead. 

Compare  opium  and  belladonna  as  to  action  on  the  heart. 

Medicinal  doses  of  belladonna  quicken  the  pulse  and  raise 


348      THEBAPEVTICS  AND  MATERIA  ME  DIG  A. 

the  arterial  pressure ;  the  quickening  of  the  pulse  results, 
from  depression  of  the  inhibitory  nerves  and  stimulation  of 
the  accelerators.  The  increased  blood  pressure  is  due  to  stim- 
ulation of  the  vasomotor  centers  and  the  heart  itself.  .  Toxic 
doses  paralyze  the  heart.  Opium  in  moderate  doses  has  little 
effect  upon  the  circulation.  Large  doses,  however,  stimulate 
the  inhibitory  nerves,  centrally  and  peripherally,  and  thus 
slow  the  pulse ;  at  the  same  time  the  latter  becomes  full  and 
strong  from  stimulation  of  the  heart  or  its  contained  ganglia, 
and  possibly  also  from  stimulation  of  the  vasomotor  centers 
in  the  medulla.  Toxic  doses  finally  paralyze  both  the  heart 
and  vagi  and  produce  a  rapid,  feeble  pulse. 

What  are  the  therapeutic  uses  of  ammonium  carbonate? 

It  is  used  principally  as  a  stimulant  in  low  fevers,  like 
typhoid,  and  in  acute  pulmonary  diseases  associated  with 
cardiac  and  respiratory  weakness,  such  as  croupous  pneu- 
monia, catarrhal  pneumonia  and  capillary  bronchitis. 

Define  solvent.     Mention  three  principal  solvents. 

Solvent  is  the  term  applied  to  the  liquid  before  the  sub- 
stance is  added  to  it,  by  which  addition  after  the  operation  is 
completed  the  combined  preparation  is  called  a  solution.  The 
chief  solvents  are  water,  alcohol  and  glycerin. 

What  is  the  source  of  aloes?  By  what  part  of  the  intes= 
tinal  tract  is  it  eliminated? 

"Aloes  is  the  inspissated  juice  of  the  leaves  of  the  Aloe  soco- 
trina  and  other  species  of  aloe.  It  acts  chiefly  on  the  lower 
half  of  the  large  intestine. 

Describe  the  physiologic  action  of  alum.  In  what  patho= 
logic  conditions  is  alum  useful? 

Alum  is  an  astringent,  coagulating  the  albumin  and  stim- 
ulating muscular  contraction.  At  first  it  excites  the  flow 
of  saliva  and  then  diminishes  it.  It  coagulates  pepsin  and 
arrests  digestion,  stops  peristalsis  and  usually  causes  consti- 
pation, although  sometimes  it  produces  diarrhea.  Although 
coagulating   albumin  even   in   weak   solution,    it    enters   the 


THERAPEUTICS  AND  MATERIA  MEDICA.      349 

blood,  arrests  secretion,  especially  those  of  mucous  surfaces, 
and  stops  capillary  hemorrhages.  It  is  used  locally  as  an 
astringent  in  chronic  catarrh,  leucorrhea,  gonorrhea,  hemor- 
rhoids, bed  sores,  colliquative  sweats,  etc.  The  dried  powder 
is  escharotic,  destroying  granulation  and  warty  growths. 
Alum  is  used  as  an  emetic  in  small  doses  in  gastric  catarrh, 
gastralgia,  lead  colic,  etc. 

Mention  the  ingredients  of  (a)  Tully's  powder,  (b) 
Dover's  powder. 

(a)  Tully's  powder  is  the  compound  powder  of  morphine. 
It  is  composed  of  morphine  sulphate  1  part,  to  19  of  camphor 
and  20  each  of  liquorice  and  calcium  carbonate,  (b)  Dover's 
powder  contains  10  parts  ipecac,  10  parts  of  powdered  opium 
and  80  parts  of  sugar  of  milk. 

Why  is  atropine  combined  with  morphine  when  the 
latter  is  administered?  What  is  the  dose  of  atropine 
when  combined  with  morphine? 

Atropine  has  long  been  regarded  as  the  physiological  an- 
tagonist of  opium.  It  especially  combats  the  depressing 
effect  of  opium  on  the  circulation.  The  hypodermic  dose  of 
atropine  sulphate  when  combined  with  morphine  is  1-150 
grain. 

Give  the  therapeutic  uses  of  sodium  phosphate. 

In  doses  of  i/^  ounce  it  is  a  mild  purgative.  It  has  been 
recommended  in  catarrhal  jaundice  and  cholelithiasis. 

State  the  ingredients  and  uses  of  sulphur  ointment. 

Sulphur  ointment  is  made  up  of  15  parts  of  washed  sul- 
phur and  85  parts  of  benzoinated  lard  thoroughly  mixed. 
Sulphur  ointment  is  used  in  certain  forms  of  skin  diseases 
and  as  a  means  of  administering  sulphur  when  it  is  not  well 
borne  by  the  stomach. 

(jive  the  composition  and  the  chief  use  of  lotio  hydrar- 
gyri  nigra. 

Black-wash  is  prepared  by  adding  30  grains  of  calomel  to 


350      THEBAPEUTICS  AND  MAT  FBI  A  ME  DIG  A. 

10  ounces  of  lime-water,  thereby  producing  the  black  oxide, 
and  is  used  as  an  application  to  syphilitic  sores. 

What  are  the  therapeutic  uses  of  Pulsatilla? 

Some  therapeutists  regard  the  drug  as  of  no  value  what- 
ever, others  claim  good  effects  from  its  employment  as  an 
emmenagogue,  a  diuretic  and  diaphoretic ;  it  is  also  a  cardiac 
and  vascular  sedative,  and  possesses  some  antipyretic  action. 

Where  is  quassia  indigenous?  What  part  of  the  plant 
is  used  as  medicine? 

The  West  Indies.     The  wood  is  used. 

What  is  the  common  name  of  ferrous  sulphate?  Give 
the  chief  uses  of  ferrous  sulphate. 

Copperas:  it  is  impure  ferrous  sulphate.  It  is  chiefly 
used  to  make  the  dry  sulphate  and  other  preparations.  It  is 
sometimes  employed  as  a  tonic  astringent. 

Describe  the  physiologic  action  and  the  therapeutic  use 
of  guarana. 

Guarana  has  similar  actions  to  those  of  coffee,  the  active 
principle  of  both  plants  being  perhaps  identical.  It  may  be 
used  in  migraine,  in  convalescence  in  acute  diseases,  in  diar- 
rhea of  phthisis,  etc. 

Give  the  composition  of  Vienna  paste  (pasta  caustica 
Viennensis). 

It  is  a  grayish-white  deliquescent  powder  consisting  of 
equal  parts  of  potassa  and  lime  rubbed  together. 

Explain  the  distinction  between  physiologic  action  and 
the  therapeutic  use  of  medicinal  agents. 

The  physiologic  action  of  a  drug  is  its  effect  upon  the 
economy  in  health,  and  includes  its  action  upon  the  nervous 
centers,  respiration,  circulation  and  metabolism.  From  its 
physiologic  action  is  deduced  its  therapeutic  indication  or  em- 
ployment in  certain  diseased  states. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      351 

Define  a  mydriatic.  Give  three  examples,  with  the  dose 
for  the  local  application  in  each  case. 

Mydriatics  are  agents  which  produce  dilatation  of  the 
pupils.  Atropine  is  used  locally  in  solutions  of  8  grains  to 
the  ounce.  Homatropine,  in  strength  of  4  grains  to  the  ounce. 
Cocaine  locally  in  a  5  per  cent,  solution. 

Define  germicides,  parasiticides. 

Germicides  are  agents  that  destroy  germs,  as  solutions  of 
bichloride  of  mercury,  permanganate  of  potash,  carbolic  acid, 
etc.  Parasiticides  are  agents  which  are  destructive  to  para- 
sites; the  principal  parasiticides  are  mercurial  ointment,  sul- 
phur and  acetic  acid. 

What  results  from  combining  silver  nitrate  and  creo= 
sote? 

An  explosive  compound,  which  is  white  in  color,  without 
odor,  and  has  the  appearance  of  an  emulsion. 

What  symptoms  are  produced  by  toxic  doses  of  tartar 
emetic? 

Pain,  vomiting,  diarrhea,  with  watery  stools  and  collapse, 
motor  and  sensory  paralysis  and  suppression  of  the  urine. 

Mention  two  remedies  commonly  used  to  increase  in= 
testinal  peristalsis. 

Senna  and  rhubarb. 

What  are  the  therapeutic  uses  of  buchu? 

Chronic  affections  of  the  genito-urinaiy  mucous  membranes, 
lithiasis,  prostatic  affections,  atonic  dyspepsia  and  chronic 
rheumatism. 

What  is  the  ultimate  effect  on  the  heart's  action  of 
medicinal  doses  of  belladonna? 

Following  the  ingestion  of  belladonna  the  heart  rate  is  at 
first  slowed,  but  soon  becomes  rapid  and  vigorous,  and  the 
arterial  tension  is  increased;  this  is  accomplished  by  stimula- 
tion of  the  cardiac  synipatlietic  and  paralysis  of  the  j)neumo- 


352      THERAPEUTICS  AND  MATERIA  ME  DIG  A. 

gastric,    thus   stimulating   the    accelerator   apparatui^  while 
lessening  the  inhibitory. 

Compare  the  strength  of  dilute  hydrochloric  acid  with 
that  of  the  absolute  acid.    What  is  the  dose  of  the  former? 

Dilute  hydrochloric  acid  is  a  10  per  cent,  solution  of  the 
absolute  acid  in  water.     Its  dose  is  1  Cc.  (15  minims). 

How  do  styptics  and  hemostatics  differ?  Give  an  ex= 
ample  of  each. 

These  are  agents  which  arrest  bleeding,  styptics  being  those 
which  are  applied  locally,  as  alum,  and  hemostatics  those 
which  are  administered  internally,  as  gallic  acid. 

What  part  of  zingiber  is  used  in  medicine?  What  are 
its  therapeutic  uses? 

The  rhizome.  The  official  preparations  are  fluid  extract, 
tincture,  syrup,  and  the  oleoresin.  It  is  employed  as  a  car- 
minative and  as  an  adjunct  to  purgative  medicine  to  prevent 
griping;  the  syrup  is  commonly  employed  as  a  flavoring  ad- 
juvant. 

Define  pharmacy. 

Pharmacy  is  the  art  of  selecting  and  preserving  medicines 
and  preparing  them  for  administration. 

How  do  therapeutic  agents  act  to  promote  waste? 

Destructive  metamorphosis  of  the  tissues  is  promoted  by 
alteratives  and  astringents.  The  manner  in  which  alteratives 
act  has  never  been  determined.  We  know  that  of  such  drugs 
as  mercury  and  iodine,  the  former  is  endowed  with  the  power 
of  breaking  up  newly-deposited  fibrin  and  disorganizing 
syphilitic  deposits,  and  the  latter  acts  energetically  upon 
the  lymphatic  system  and  promotes  absorption. 

Mention  the  principal  therapeutic  application  of  anti-^ 
pyrine. 

Antipyretic,  analgesic,  antiseptic,  as  a  local  anesthetic  and 
to  diminish  secretion,  as  an  anti-galactagogue. 


THEBAPEUTIGS  AND  MATERIA  MEDICA.      353 

What  is  the  dose  of  curare  for  hypodermic  use?  What 
are  the  antagonists  of  curare? 

Dose  V20  to  Yq  grain.  Strychnine,  atropine,  and  more  ef- 
fective still,  artificial  respiration. 

What  is  codeine?  State  the  dose  of  codeine.  What  are 
the  advantages  of  codeine  over  opium? 

Codeine  is  an  alkaloid  of  opium,  differing  from  morphine 
in  having  the  radical  CH3  replacing  an  atom  of  hydrogen.  It 
is  less  irritating  to  the  digestive  tract  than  opium.  Its  dose 
is  0.030  Gm.  (1/2  grain). 

Mention  the  therapeutic  uses  of  creosote. 

Locally  as  an  anesthetic  and  antiseptic.  Internally  as  an 
antiseptic,  in  chronic  gastric  catarrh,  in  diarrhea,  dysentery 
•and  phthisis. 

What  is  the  common  name  of  hamamelis?  State  the 
dose  of  the  fluid  extract  of  hamamelis. 

Witch-hazel.  The  dose  of  the  fluid  extract  is  2  Cc.  (30 
minims) . 

What  part  of  buchu  is  used  in  medicine?  State  the  dose 
of  the  fluid  extract  of  buchu. 

The  lenvos.     Dose  of  the  fluid  extract  2  Ce.  (30  minims). 

What  is  the  official  name  of  tartar  emetic?  State  the 
dose  of  tartar  emetic. 

Antimonii  et  potassi  tartras.     Dose  as  expectorant,  0.005 

Om.  (Vio  grain)  :  as  emetic.  0.030  Gm.  (i/^  grain). 

What  are  the  uses  of  cantharis  (a)  externally  applied, 
(b)   internally  administered? 

Externally  it  is  employed  as  a  vesicant  and  internally  as  a 

stimulant  to  the  genito-nrinary  tract. 

What  is  pepo?    State  its  therapeutic  use. 

Punifikin-seed.  It  is  used  as  an  anthelmintic  against  tape- 
worms. 

23 


354      THEBAPEUTICS  AND  MATERIA  MEDIC  A. 

Describe  the  physiologic  action  and  the  therapeutic  uses 
of  scammonium. 

Scammony  is  a  powerful  irritating  hydragogue  cathartic. 
It  may  be  used  in  combination  with  other  cathartics  in  obsti- 
nate constipation. 

Mention  the  preparations  of  ergot  and  give  the  dose  of 
each  preparation. 

The  extract  of  ergot,  dose  0.250  Gm.,  (4  grains)  ;  the  fluid 
extract,  dose  2  Cc.  (30  minims)  ;  the  wine,  dose  8  Cc.  (2  fluid- 
drachms). 

Define  hematics.     Mention  two  principal  hematics. 

These  are  medicines  which  increase  the  quantity  of  hematin 
in  the  blood.  They  consist  chiefly  of  iron  and  manganese 
and  their  compounds. 

What  are  the  physiologic  effects  of  iodoform  internally 
administered?  State  the  therapeutic  uses  of  iodoform 
when  externally  applied. 

In  small  doses  internally  iodoform  is  considered  to  be  a 
tonic  and  alterative.  If  taken  over  a  protracted  period  it  may 
cause  profuse  salivation.  In  toxic  doses  it  causes  pyrexia, 
then  headache,  quick  and  feeble  pulse,  marked  anxiety  and 
restlessness;  collapse  and  death  may  suddenly  supervene. 
Locally  its  action  is  anesthetic  and  powerfully  antiseptic.  It 
is  one  of  the  best  agents  to  prevent  decomposition,  and  it 
destroys  the  germs  of  putrefaction  and  of  disease,  but  must 
be  carefully  employed. 

Qive  the  dose  of  (a)  liquor  potassii  arsenitis,  (b)  liquor 
sodii  arsenatis. 

(a)  0.2  Gc.  (3  minims),     (b)  0.2  Cc.  (3  minims). 
Define  emulsion. 

Emulsions  are  liquid  preparations  containing  an  insoluble 
medicinal  substance,  as  an  oil  or  a  resin,  in  a  state  of  minute 
subdivision,  and  suspended  by  the  aid  of  some  viscid  excip- 
ient,  as  gum,  which  either  may  be  contained  in  the  medicinal 
ingredient  itself  or  be  added  by  the  pharmaceutist. 


THERAPEUTICS  AND  MATERIA  MEDICA.      355 

Where  is  the  habitat  and  what  are  the  physiologic 
effects  of  digitalis? 

It  grows  wild  in  Europe  and  is  cultivated  in  this  country. 
The  dominant  action  of  digitalis  is  on  the  circulation.  In 
therapeutic  doses  it  slows  the  pulse  and  raises  the  blood  pres- 
sure. The  slowing  of  the  pulse  results  from  a  prolongation 
of  the  diastole,  and  this  in  turn  is  due  to  stimulation  of  the 
vagi  or  inhibitory  nerves.  The  increased  blood  pressure  is 
due  to  a  powerful  stimulant  effect  on  the  heart  and  to  a  con- 
traction of  the .  arterioles  resulting  indirectly  from  stimula- 
tion of  the  vasomotor  center  and  directly  from  the  action  of 
the  drug  on  the  vessel  wall.  Toxic  doses  quicken  the  pulse 
by  paralyzing  the  vagi,  and  lower  the  arterial  pressure  by 
causing  a  powerful  systolic  contraction  so  that  the  diastole 
becomes  too  imperfect  to  permit  the  ventricles  to  be  completely 
filled.  Therapeutic  doses  have  no  effect  on  the  nervous  sys- 
tem, but  toxic  doses  lessen  the  reflexes,  first  by  stimulating 
Setschenow's  inhibitory  centers,  and  later  by  depressing  the 
spinal  cord.  It  requires  toxic  doses  to  influence  the  respira- 
tion, and  then  slowing  occurs.  Large  doses  occasionally  pro- 
duce nausea,  vomiting  and  diarrhea.  In  health,  digitalis  has 
little  or  no  diuretic  action.  "When  the  urine  is  diminished 
from  embarrassment  of  the  circulation  it  produces  free  diur- 
esis, which  is  attributed  to  its  effect  on  the  heart  and  vessels, 
and  not  to  a  direct  influence  on  the  secreting  structure  of 
the  kidney. 

State  the  source  of  ichthyol  and  give  its  uses  in  medi- 
cine. 

Ichthyol  is  a  product  of  the  distillation  of  bituminous 
rocks  from  the  Tyrol,  which  contain  fossil  fishes.  It  is  useful 
in  certain  chronic  skin  diseases,  particularly  eczema  and 
psoriasis.  It  is  extensively  used  externally  for  its  antiseptic 
and  alterative  properties  in  rheumatism,  erysipelas  and  lym- 
phatic enlargements.  Combined  with  glycerin,  it  is  valuable, 
locally  applied,  in  the  various  inflammatory  affections  of  the 
female  genital  organs. 


356      THERAPEUTICS  AND  MATERIA  MEDIC  A. 

What  are  the  therapeutic  uses  of  aconite?  Give  the 
dose  of  the  fluid  extract  of  this  drug. 

Aconite  is  used  locally  in  neuralgia;  internally  in  hyper- 
emesis,  in  acute  inflammation,  such  as  tonsillitis,  bronchitis 
and  pneumonia,  in  excessive  hypertrophy  of  the  heart,  in 
nervous  palpitation,  in  the  tachycardia  of  exophthalmic  goiter 
and  in  active  cerebral  congestion  with  high  arterial  tension. 
Dose  of  fluid  extract  is  0.05  Cc.  (1  minim). 

What  part  of  scoparius  is  used  in  medicine?  What 
alkaloid  is  derived  from  scoparius? 

The  tops  of  cytisus  scoparius.    Its  alkaloid  is  sparteine. 

Give  the  common  name  of  taraxacum  and  state  what 
part  of  this  plant  is  used  in  medicine. 

Dandelion.     The  root  is  used  in  medicine. 

What  is  the  physiologic  action  of  tincture  of  the  chlor= 
ide  of  iron  upon  the  kidneys? 

The  tincture  of  the  chloride  is  considered  diuretic. 

Give  the  chief  source  and  the  dose  of  gallic  acid. 

It  is  prepared  from  a  paste  of  powdered  galls  by  ferment- 
ing for  six  weeks,  boiling  and  reboiling  in  water,  filtering 
and  crystallizing.    Dose,  1  Gm.  (15  grains). 

Give  the  dose  of  hyoscine  for  hypodermic  use.  For  what 
purpose  is  hyoscine  used? 

The  dose  of  hyoscine  hydrobromide  hypodermically  is 
0.0005  Gm.  (Vi28  grain).  Hyoscine  is  a  cerebral  and  spinal 
sedative,  a  powerful  hypnotic.  It  is  employed  as  anodyne 
when  opium  is  contra-indicaited. 

What  is  an  excipient?    Give  examples. 

Excipients  are  substances  which  give  form  and  consistence 
to  prescriptions  and  serve  as  vehicles  for  the  exhibition  of 
the  other  ingredients.  Examples  are  syrups,  acacia  and  the 
various  flavoring  agents,  such  as  syrup  of  lemon. 


THERAPEUTICS  AND  MATERIA  ME  DIG  A.      357 

Describe  the  technique  of  venesection. 

The  patient  having  been  placed  in  a  semi-recumbent  posi- 
tion, the  arm  should  be  constricted  three  or  four  inches 
above  the  elbow  by  a  few  turns  of  a  roller  or  a  twisted  hand- 
kerchief;  if  this  is  not  sufficient  to  render  the  veins  promi- 
nent, the  arm  may  be  rubbed  for  a  few  minutes  from  below 
upwards.  A  large  vein  having  been  selected,  it  should  be 
incised  by  a  thumb-lancet  or  a  spring-lancet  in  a  direction 
oblique  to  the  long  axis  of  the  vessel.  The  amount  of  blood 
abstracted  will  depend  entirely  upon  the  pulse,  which  should 
be  carefully  observed  during  the  operation,  and  when  it  les- 
sens in  force  and  becomes  more  compressible  the  bleeding 
must  be  suspended. 

Define  glycosides  and  give  two  examples. 

Glucosides  form  a  group  of  organic  principles  existing  in 
plants,  and  are  generally  neutral  in  character.  Examples 
are  salicin,  obtained  from  willow  and  other  barks,  and  glycyr- 
rhizin,  from  liquorice  root. 

What  is  the  most  active  laxative  ingredient  in  pulvis 
glycyrrhizae  compositus? 

Senna. 

By  what  methods  do  antipyretics  act?  Give  an  example 
of  one  that  acts  by  each  method. 

Antipyretics  reduce  the  body  temperature  in  fever:  (a) 
by  lessening  the  production  of  heat — (1)  by  diminishing 
tissue  change,  (2)  reducing  the  circulation;  or  (b)  promot- 
ing the  loss  of  heat — by  (3)  dilating  the  cutaneous  vessels; 
(4)  producing  perspiration,  and  (5)  abstracting  heat  from 
the  body.  Examples  of  antipyretics  acting  in  the  order 
named  are  as  follows:  Quinine  (1),  digitalis  (2),  carbolic 
acid  (1  and  3).  antipyrine  (1  and  4),  cold  sponging  (5). 

Indicate  the  common  name  and  give  the  preparations  of 
serpentaria. 

Virginia  snake-root.     The   preparations  are   the   fluid   ex- 


358      THERAPEUTICS  AND  MATERIA  ME  DIG  A. 

tract  and  the  tincture.     It  also  is  one  of  the  components  of 
compound  tincture  of  cinchona. 

What  are  the  therapeutic  uses  and  the  official  prepara= 
tions  of  oleic  acid? 

Oleic  acid  is  used  only  in  making  the  oleates.  Three  prep- 
arations are  official,  the  oleate  of  mercury,  the  oleate  of  vera- 
trine  and  the  oleate  of  zinc. 

What  is  the  antidote  for  strychnine? 

Chloral  hydrate. 

Describe  the  manner  of  making  barley  water  as  food 
for  the  patient. 

It  may  be  made  as  follows :  Grind  I/2  ounce  of  pearl  barley 
in  a  coffee-mill,  add  6  ounces  of  water,  boil  20  minutes,  add 
salt  and  strain. 

What  are  the  therapeutic  uses  of  the  preparations  of 
silver? 

The  nitrate  is  the  most  soluble  of  the  silver  salts ;  it  is  anti- 
septic, astringent,  hemostatic,  irritant,  and  a  limited  escha- 
rotic,  also  anti-phlogistic,  anti-spasmodic  and  tonic.  The 
oxide  is  the  least  irritant,  and  does  not  discolor  the  skin  so 
quickly.  Internally  it  has  been  used  in  gastric  neuralgia,  ir- 
ritable dyspepsia,  pyrosis,  gastric  and  pulmonary  hemorr- 
hages, dysmenorrhea,  menorrhagia,  to  check  profuse  sweat- 
ing, to  control  vomiting,  and  in  diarrhea  depending  on  reflex 
nervous  irritation.     The  iodide  is  similarly  employed. 

How  would  you  distinguish  chemically  between  ether 
and  chloroform? 

Ether  is  ethyl  oxide  (02115)20.  Chloroform  is  trichlor- 
methane,  CHCI3. 

Name  four  drugs  used  in  the  treatment  of  chronic  inter- 
stitial nephritis. 

Nitroglycerin,  Basham's  mixture,  caffeine,  and  magnesium 
sulphate. 


THERAPEUTICS  AND  MATERIA  MEDICA.      359 

Give  the  therapeutic  uses  of  caffeine. 

Cardiac  stimulant  in  cardiac  and  renal  dropsy,  and  alone 
■or  in  combination  with  antipyrine  or  the  bromides  in  nervous 
headache  and  migraine. 

Describe  the  physiologic  action  of  aconite. 

It  is  a  powerful  depressant  of  the  sensory  nerve  ends,  the 
nervous  and  muscular  apparatus  of  the  heart  and  respiration, 
■and  the  spinal  nervous  system.  It  is  also  antipyretic,  dia- 
phoretic and  diuretic. 

Name  the  official  preparations  and  doses  of  digitalis, 
cascara  sagrada  and  ipecacuanha. 

Digitalis,  the  extract,  dose  0.010  Gm.  (Vn  grain)  ;  the  fluid 
•extract.  0.05  Cc.  (1  minim)  ;  the  infusion,  8  Cc.  (2  fluid- 
rachms)  :  the  tincture,  1  Cc.  (15  minims).  Cascara  sagrada, 
the  fluid  extract,  dose  1  Cc.  (15  minims).  Ipecacuanha,  the 
fluid  extract,  emetic  dose  1  Cc.  (15  minims)  ;  expectorant 
■dose  0.05  Cc.  (1  minim)  ;  Dover's  powder,  0.500  Gm.  {1^2 
grains)  ;  the  syrup,  emetic  dose  15  Cc.  (4  fluidrachms),  ex- 
pectorant dose  1  Cc.  (15  minims)  :  wine  of  ipecac,  dose  1 
Cc.  (15  minims) . 

Name  four  efficient  hypnotics  and  give  the  source  and 
^ose  of  each.  > 

Sulphate  of  morphine  derived  from  opium,  dose  0.015  Gm. 
(1/4  grain)  ;  hyoscine,  an  alkaloid  of  hyoscyamus,  dose  of  the 
hydrochloride,  0.0005  Gm.  (Vi2r  grain)  ;  chloral  hydrate  ob- 
tained from  the  action  of  chlorine  on  aldehyde,  dose  1  Gm. 
(15  grains)  :  sulphonmethane,  or  sul phonal,  a  synthetic  prod- 
uct obtained  by  the  oxidation  of  a  mixture  of  ethyl-mercaptan 
?»nd  acetone,  dose  1  Gm.  (15  grains). 

Write  a  prescription  for  (a)  a  collyrium,  (b)  a  supposi- 
tory, (c)  a  mouth-wash. 

(■)   R     Acidi  borici gr.  x 

Aquae  camphonp. 

Aquae  destillatse  aa  q.  h.  ad f  5.) 

Sig. — Fifteen  drops  in  both  eyeH  thrice  daily. 


360      THERAPEUTICS  AND  MATERIA  ME  DIG  A, 

C")  R     Pulveris  opii gr.  j 

lodoformi gi"-  j 

Olei  theobioin,  q.  s 

Ft.  in  supposiloria  No.  1. 
Sig. — Use  on  retiring. 

(")   R     Potassii  chloratis gr.  Ixxx 

Aquae  laurocerasi f  §  viij 

M.  S. — Use  as  mouth-wash. 

Name  five  antiseptics  and  tell  in  what  proportions  eacb 
should  be  diluted  for  surgical  purposes. 

Bichloride  of  mercury,  1  to  1000.  Permangauate  of  po- 
tassium, 25  grains  to  the  pint.  Boric  acid,  15  grains  to  thfr 
ounce.  Carbolic  acid,  5  per  cent,  solution  in  glycerin  and 
water.  Peroxide  of  hydrogen,  the  full  strength  of  the  offi- 
cial preparation  is  3  per  cent.,  by  weight. 

Describe  the  physiologic  action  of  hyoscine  and  name  a. 
physiologic  antidote. 

It  is  a  cerebral  and  spinal  sedative  and  powerful  hypnotic, 
directly  depressing  the  higher  function  of  the  brain  and' 
affecting  the  heart  but  feebly.    Tannin  and  morphine. 

Give  the  composition  of  the  official  compound  cathartic 
pill. 

Compound  extract  of  colocynth,  80  parts;  resin  of  jalap, 
20  parts;  mild  chloride  of  mercury,  60  parts;  gamboge,  15- 
parts. 

Describe  two  escharotics  and  tell  how  you  would  apply 
them. 

Nitrate  of  silver  applied  in  the  form  of  lunar  caustic  is  an 
efficient  superficial  escharotic ;  carbolic  acid  is  escharotic,  and' 
should  be  used  in  strong  solution,  1  to  10. 

Write  a  correct  prescription  containing  nitrate  of  silver^ 

Argenti  nitratis gr.  iij 

Gum  Tragacanth,  q.  s. 

Ft. — In  pil.  no.  xii. 

Sig. — One  before  meals.  John  Jonkh,  M.  D. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      361 

State  the  direct  and  indirect  effect  of  pilocarpine  in 
dropsical  effusion. 

It  causes  prompt  and  profuse  perspiration  and  salivation, 
increases  the  bronchial  and  lachrymal  secretion,  and  some- 
times causes  serous  diarrhea.  Full  doses  cause  a  decrease  in 
arterial  tension.  The  elimination  of  urea  is  greatly  increased, 
but  not  the  quantity  of  the  urine. 

What  are  the  physiological  effects  of  nux  vomica  on  the 
nerves  and  circulatory  system? 

It  is  a  powerful  stimulant  of  the  spinal  cord,  especially  the 
motor  columns.  In  toxic  doses  it  produces  spinal  convul- 
sions. Small  amounts  stimulate  the  brain  and  increase  the 
mental  powers.  In  moderate  doses  the  heart  is  stimulated  and 
the  arterial  pressure  raised  by  stimulation  of  the  vasomotor 
center  of  the  medulla. 

What  is  wrong  with  the  following  prescription? 

R     AigentiP  nitratis draiii.s,  one 

Sodi  chloridum drams,  four 

Syrupus  lemon  is,  q.  s ounces,  four 

Take  a  tablespoonful  after  meals  in  water. 

ArgentcB  should  read  argenti;  sodi  chloridvm  should  read 
sodii  chloridi;  syrupus  lemonis  should  read  syi'upus  limonis. 
This  prescription  affords  the  example  of  a  pharmaceutical 
incompatibility.  Nitrate  of  silver  should  not  be  compounded 
with  sodium  chloride,  for  there  results  the  insoluble  chloride 
of  silver. 

Write  for  an  adult  a  complete  prescription  for  a  diarrhea 
mixture  containing  three  remedies  and  the  excipient. 

R     Creta;  preparatse 3  ii 

Tincturte  catechu 5  ^>^ 

Tincturx  opii IRlxxx 

.\qua  cinnamonii  ad •  3  ^'''' 

M.  Sig. — Two  teaspoonfuls  every  four  iioure. 

Name  the  official  preparations  of  belladonna  and  the 
dose  of  those  used  internally. 

Extractum  bolladonnjc  foliorum.  dose  0.010  Gra.  (I5  grain)  ; 


^362      THERAPEUTICS  AND  MATERIA  MEDICA. 

tinctura  belladonnae  foliorum,  dose  0.5  Cc.  (8  minims)  ;  fluid- 
■extraetum  belladonnae  radieis,  dose  0.05  Ce.  (1  minim)  ;  em- 
plastrum  belladonnae ;  unguentum  belladonnae. 

Write  a  prescription  containing  oil  of  sandal  wood  and 
at  least  one  other  constituent  for  chronic  cystitis. 

Jan.  1,  1910.  For  William  Smith. 

R     Olei  santali f  §  i 

Salol §  i 

Ft.  in  capsules  no.  xii. 

Sig. — One  after  meals.  Wm.  Jonks,  M.  D. 

Define  narcotics,  anesthetics  and  sedatives,  and  give  an 
example  of  each. 

Narcotics  are  agents  which  lessen  pain  and  produce  sleep 
or  stupor;  example,  opium.  Anesthetics  are  agents  which 
temporarily  destroy  sensation ;  they  are  both  general  and 
local;  example,  ether  as  a  general  anesthetic  and  chloride  of 
«thyl  as  a  local  anesthetic.  Sedatives  are  agents  which  exert 
a  soothing  influence  on  the  system  by  lessening  functional 
-activity,  depressing  motility  and  diminishing  pain;  example, 
the  bromides. 

Treat  a  case  of  opium  poisoning;  also  give  the  thera= 
peutic  uses  of  opium. 

The  stomach  should  be  emptied  by  the  stomach-pump  or  a 
stimulating  emetic,  like  sulphate  of  zinc  or  mustard.  Pre- 
vious to  this,  however,  if  the  opium  is  in  the  stomach,  solution 
of  permanganate  of  potash  should  be  administered  freely  as 
a  chemical  antidote,  strong  coffee  should  be  given,  and  the 
patient  should  be  aroused  by  flagellation,  douching,  or  forced 
walking.  Atropine  and  strychnine  should  be  given  hypo- 
•dermically.  The  temperature  should  be  maintained  by  the 
■external  application  of  heat.  In  therapeutics  opium  is  used 
internally  to  produce  sleep,  to  relieve  pain,  to  lessen  nervous 
•excitement,  to  promote  diaphoresis,  to  check  hemorrhage,  and 
to  support  the  system.    Externally  it  is  used  as  a  sedative. 

Name  five  emetics  and  give  the  dose  of  each. 

Alum,   dose   1   to  4   drams ;   mustard,   dose  1  to  4  drams ; 


THERAPEUTICS  AND  MATERIA  MEDICA.      363 

ipecac,   dose  of  the  fluid  extract  15  minims;   apomorphine, 
dose  Vio  grain;  sulphate  of  zinc,  dose  15  grains. 

What  are  the  advantages  and  disadvantages  in  the  use 
of  chloroform  as  an  anesthetic  and  what  are  the  signs  in= 
dicative  of  danger  in  the  patient? 

Inhalations  of  chloroform  produce  sensations  which  are 
rather  agreeable  than  otherwise,  while  the  first  stage  of  ether 
anesthesia  is  decidedly  unpleasant.  Chloroform  produces 
anesthesia  more  quickly  than  ether,  and  in  certain  cases  this 
is  an  advantage.  It  is,  however,  much  more  dangerous  than 
ether.  Its  dangerous  symptoms  are:  (1)  respiration  becomes 
stertorous  or  shallow;  (2)  sudden  dilatation  of  the  pupils; 
(3)  signs  of  cardiac  failure.  Chloroform  produces  much  less 
subsequent  vomiting. 

Define  briefly  but  clearly  serum  therapy. 

Serum  therapy  properly  means  the  prophylactic  and  cur- 
ative treatment  of  certain  acute  infectious  diseases  by  the 
subcutaneous  injection  of  a  blood  serum  containing  an  anti- 
toxin specific  to  the  particular  disease.  As  generally  used, 
however,  this  term  includes  the  treatment  of  the  same  dis- 
orders by  the  toxins  produced  by  attenuated  cultures  of  their 
respective  microbes;  but  these  toxins,  though  sometimes 
grown  on  blood  serum,  may  be  cultivated  on  other  media, 
and  are  never  administered  in  a  serum,  as  the  antitoxins  in- 
variably are.  The  antitoxins  at  present  employed  in  serum 
therapy  are  those  of  diphtheria,  tetanus,  tuberculosis,  erysip- 
elas, pyemia,  pneumonia,  cholera,  syphilis,  plague,  and  ty- 
phoid fever,  but  only  the  first  three  have  come  into  anything 
like  general  use.     (Potter.) 

What  official  preparations  are  derived  from  the  willow? 

Salicinum  or  salicin,  a  glucoside,  is  obtained  from  several 
species  of  the  willow.  Salicylic  acid  and  the  various  sali- 
cylates might  be  prepared  from  salicin  by  synthetic  processes 
hilt  practically  this  is  never  done. 


364      THERAPEUTICS  AND  MATERIA  MEDIGA. 

What  active  principles  are  found  in  digitalis?  What 
are  the  official  preparations  of  petroleum? 

Glucosides,  digitalin,  digitoxin,  digitalein,  digitonin,  and 
digitin.  Petrolatum  is  a  mixture  of  the  liydrocarbons  ob- 
tained from  petroleum.  The  official  preparations  are  petro- 
latum, petrolatum  album,  and  petrolatum  liquidum. 

Give  the  physiologic  action  and  therapy  of  saline  pur= 
gatives. 

This  group  includes  the  neutral  salts  of  metals  of  the  alka- 
line or  alkaline  earths.  They  stimulate  the  intestinal  glands. 
to  increased  secretion,  and  by  their  low  diffusibility  impede 
re-absorption,  causing  an  accumulation  of  fluid  in  the  intes- 
tinal tract.  This,  partly  from  the  effect  of  gravity  and  partly 
by  gentle  stimulation  of  peristalsis  excited  by  distension^ 
reaches  the  rectum  and  produces  a  copious  evacuation.  Mag- 
nesium sulphate  and  sodium  sulphate  are  the  typical  salines 
They  should  be  given  in  plenty  of  water  and  during  active 
movement  (as  in  walking)  in  order  to  produce  their  best 
effects. 

Name  three  drugs  used  in  the  treatment  of  intermittent 
fever.     State  how  each  controls  this  disease. 

Quinine  exerts  a  specific  influence  in  all  malarial  infections 
by  reason  of  its  power  to  prevent  the  development  of  the 
Plasmodium  to  which  malaria  is  due.  A  10-grain  dose  of  the 
sulphate  should  be  given  in  the  sweating  stage,  and  again 
five  hours  before  the  expected  time  of  the  next  paroxysm.  In 
the  intervals  arsenic  is  of  more  value ;  its  therapeutic  action 
is  due  to  the  fact  that  it  is  a  valuable  anti-periodic,  as  well 
as  tonic  and  alterative.  Mercury  is  also  of  value  for  its 
hematinic  and  alterative  properties. 

Describe  the  treatment  of  intestinal   indigestion. 

Under  this  term  a  variety  of  conditions  have  been  described 
dependent  upon  various  causas,  but  it  is  usually  restricted  to 
acute  or  chronic  intestinal  catarrh.  When  this  is  dependent 
upon   causes   residing   in   the   stomach    the   existing   gastritis. 


THERAPEUTICS  AND  MATERIA  MEDICA.      365 

must  be  first  treated.  A  course  of  calomel  and  soda  is  of 
value;  this  may  be  followed  by  the  administration  of  pan- 
creatin,  which  will  aid  digestion.  Proper  measures  of  diet 
and  exercise  are  important.  Charcoal  in  10-^0-grain  doses  is 
useful. 

Name  four  drugs  incompatible  with  tannic  acid.  Name 
two  incompatible  with  hyoscyamus. 

Tartar  emetic,  lead  acetate,  silver  nitrate  and  hydrochloric 
acid  are  incompatible  with  tannic  acid.  The  hydroxide  of 
potassium  and  tannin  with  hyoscyamus. 

What  doses  of  antitoxin  are  used  for  a  child  five  years 
old  ill  with  diphtheria?  What  would  be  the  prophylactic 
dose  for  the  same  child? 

1500  units.    500  units. 

Correct  the  following  prescription: 

.\tropi8e  .sulphati grs.  iss 

Potas.  io(Ji(li .}  oz. 

Infusae  digitalis l  H  oz. 

Elix.  simpl.  q.  s.  ad 2  fl  o/.. 

M.  S. — Tea.spoonfiil  in  water  four  times  a  day. 

Potassium  iodide  is  best  given  alone.  The  dose  of  atropine 
is  much  too  great.  It  should  be  about  ^/joo  grain  to  each 
dram.  Atropicr  sulphati  should  read  Atropincr  sulphatis. 
Infnscr  should  read  Infusi. 

What  parts  of  gossypium  are  used  in  medicine? 

The  bark  of  the  root  is  official  as  gossypii  cortex,  and  the 
hairs  of  the  seed  as  gossypium  purificatum. 

What  is  the  important  alkaloid  of  erythroxylon  and 
what  is  its  principal  therapeutic  use? 

Its  alkaloid,  cocaine,  is  allied  to  caffeine,  but  is  more  pow- 
erful, and  its  proportion  in  the  leaves  of  the  plant  varies 
greatly  in  the  different  samples  which  occur  in  commerce. 
Its  chief  use  is  that  of  a  local  anesthetic. 


366      THERAPEUTICS  AND  MATERIA  MEDICA. 

Name  the  official  preparations  of  bismuth  and  give  the 
dose  of  each. 

Bismuth  citrate,  0.125  Gm.  (2  grains)  ;  bismuth  and  am- 
monium citrate,  0.125  Gm.  (2  grains)  ;  bismuth  subcarbonate, 
0.500  Gm.  (71/2  grains)  ;  bismuth  subgallate,  0.250  Gm.  (4 
grains  ;  bismuth  subnitrate,  0.500  Gm.  (7%  grains)  ;  bis- 
muth subsalicylate,  0.250  Gm.  (4  grains). 

What  is  the  physiologic  action  of  iris? 

Iris  when  fresh  is  actively  purgative,  emetic  and  diuretic, 
producing  severe  nausea  and  prostration. 

What  is  the  dose  of  (a)  potassium  iodide,  (b)  ammo= 
nium  iodide,  (c)  sodium  iodide? 

(a)  0.500  Gm.  (71/2  grains);  (b)  0.250  Gm.  (4  grains); 
(c)  0.500  Gm.  (71/2  grains). 

From  what  is  koumiss  made  and  what  are  its  thera= 
peutic  uses? 

Koumiss  is  an  eft'ervescing  fermented  liquor  originally  pre- 
pared by  the  Tartars  from  mares'  milk,  but  now  imitated 
with  cows'  milk  by  adding  sugar  of  milk,  fermenting  in  an 
open  tank,  skimming  off  the  casein  and  butter,  then  bottling 
during  active  fermentation.  Koumiss  is  an  invaluable  article 
of  diet  in  many  wasting  diseases,  especially  tuberculosis.  It 
is  of  great  benefit  in  dyspepsia,  the  diarrheas  of  children, 
convalescence  from  acute  maladies,  chronic  affections  of  the 
kidneys,  chronic  bronchitis  and  other  cachexise. 

What  is  the  proportion  of  mercury  in  hydrargyrum  cum 
creta?     What  is  the  dose? 

38%  mercury.    Dose,  0.250  Gm.  (4  grains). 

Compare  the  therapeutic  uses  of  pepsin  and  pancreatin. 
How  are  these  remedies  prepared? 

Pepsin  is  the  digestive  principle  of  gastric  juice.  Pan- 
creatin is  a  mixture  of  the  enzymes  naturally  existing  in  the 
pancreas  of  warm-blooded  animals.  Pepsin  is  usually  ob- 
tained  from    a    solution    prepared    by   digesting   the   mucua 


THERAPEITICS  AND  MATERIA  MEDIC  A.      367 

scraped  from  the  rennet-bags  of  sheep  or  the  stomach  of  the 
pig  in  acidulated  water  for  several  days.  It  is  then  precipi- 
tated by  sodium  chloride,  lead  acetate  or  alcohol.  Pancreatin 
is  usually  obtained  from  the  fresh  pancreas  of  the  hog.  Pep- 
.sin  is  employed  in  cases  of  gastric  indigestion,  while  pancre- 
atin is  indicated  in  intestinal  indigestion. 

Describe  the  therapeutic  action  of  spigelia.  What  are 
its  therapeutic  uses? 

Spilegia,  pink  root,  is  anthelminitic  against  the  round-worm 
and  is  usually  administered  with  senna.  In  large  doses  it  is 
an  uncertain  cathartic,  and  may  produce  serious  symptoms, 
including  vertigo,  dimness  of  vision,  dilated  pupils,  and  con- 
vulsions. 

What  are  the  therapeutic  uses  of  cannabis  and  what  is 
the  dose  of  the  tincture  of  cannabis  indica? 

It  is  used  as  a  sedative  and  soporific  as  a  substitute  for 
opium  in  such  conditions  as  chronic  bronchitis,  phthisis,  in 
the  dyspnea  of  asthma,  and  in  the  restlessness  of  chronic- 
nephritis.  As  an  analgesic  it  is  useful  in  neuralgia  and  mi- 
graine. It  is  also  employed  in  mania,  delirium  tremens,  and 
in  some  forms  of  dysmenorrhea  and  menorrhagia.  The  dose 
of  the  tincture  is  0.6  Cc.  (10  minims). 

What  is  the  composition  of  hydrargyri  iodidum  rubrum? 

It  is  a  red  powder  prepared  by  the  double  decomposition 
of  potassium  iodide.  5  parts,  and  mercuric  chloride.  4  parts. 

Where  is  the  cinchona  tree  indigenous?  What  part  of 
the  tree  is  used  in  medicine? 

It  is  a  native  of  the  eastern  slope  of  the  Andes.    The  bark. 

Name  three  drugs  used  to  retard  the  heart's  action  and 
state  the  dose  of  some  preparation  of  each. 

Aconite,  dose  of  the  tincture,  0.3  Cc.  (5  minims)  ;  anti- 
mony, dose  of  tartar  emetic,  0.005  Gm.  (V,o  grain)  :  vera- 
truiii.  dose  of  the  tincture  1  Cc.  (15  minims). 


368      THERAPEUTICS  AND  MATERIA  ME  DIG  A. 

Describe  the  symptoms  of  hydrargyrism. 

The  first  symptoms  of  chronic  mercurial  poisoning  are  fetid 
breath,  swollen  and  spongy  gums  having  a  bluish  line  along 
their  margin,  stomatitis,  sore  and  loosened  teeth,  salivation. 
Anorexia,  diarrhea  and  fever  follow,  also  ulceration,  and  in 
some  cases  even  gangrene  of  the  lips  and  tongue.  There  is 
destruction  of  tissue  and  various  nervous  disturbances.  The 
patient  becomes  emaciated,  suffers  from  headache,  insomnia, 
neuralgia  and  tremor,  a  vesicular  or  pustular  eruption  ap- 
pears, and  finally  there  follow  coma  and  convulsions. 

Give  the  common  name  and  state  the  physiologic  effects 
of  mentha  piperita. 

Peppermint.  It  is  an  aromatic  stimulant,  also  carminative 
and  anti-spasmodic.  It  is  used  in  the  form  of  menthol,  as 
an  antiseptic  and  local  anesthetic.  Peppermint  is  employed 
internally  for  the  relief  of  nausea  and  colic  and  as  a  car- 
minative. It  is  an  agreeable  corrigent  for  combination  with 
purgatives  to  prevent  griping. 

Of  what  is  iodoform  a  preparation  and  what  is  the  dose 
for  internal  administration? 

Iodoform  contains  from  94  to  97  per  cent,  of  iodine.  Dose, 
0.250  Gm.  (4  grains). 

What  are  the  sources  of  salicylic  acid? 

Salicylic  acid  is  an  organic  acid  existing  naturally  in  com- 
bination in  various  plants,  but  generally  prepared  syntheti- 
cally from  carbolic  acid. 

Give  the  source  and  describe  the  uses  of  lanolin. 

Lanolin  is  the  purified  fat  of  the  wool  of  sheep  mixed  with 
not  more  than  30  per  cent,  of  water.  It  is  useful  in  chronic 
skin  diseases  where  there  is  infiltration  and  where  a  penetra- 
tive action  is  required  for  medicaments  locally  applied. 

How  do  oleates  and  ointments  differ? 

Oleates  are  liquid  solutions  of  metallic  salts,  or  alkaloids  in 
oleic  acid  intended  for  external  administration.     Ointments 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      369 

-are  soft,  fatty  mixtures  of  medicinal  agents  with  a  basis  of 
lard,  petrolatum,  etc.  They  are  intended  for  application  to 
the  skin  by  inunction,  and  have  a  melting  point  which  is 
below  the  ordinary  temperature  of  the  human  body. 

What  are  the  therapeutic  uses  of  acetanilide  adminis= 
tered  internally?  Has  it  any  uses  when  locally  applied? 
If  so,  what  are  they? 

It  is  used  internally  as  an  antipyretic  and  an  analgesic  and 
antispasmodic.  It  is  extensively  employed  in  surgical  prac- 
tice as  a  dry  dressing  for  wounds,  etc. 

Describe  linum  and  give  its  medical  preparations  and 
uses. 

Flaxseed  is  the  seed  of  linum  usitatissimum.  It  contains 
15  per  cent,  of  mucilage  in  the  epithelium,  also  30  to  40 
per  cent,  of  fixed  oil  in  the  embryo.  Linseed  oil  is  official. 
Linseed  tea  is  in  common  use,  but  is  not  official.  Carron  oil, 
s  favorite  application  for  burns,  consists  of  equal  parts  of 
linseed  oil  and  lime-water.  Linseed  is  demulcent,  emollient, 
■expectorant  and  diuretic.  The  oil  is  laxative  in  doses  of  1 
ounce.  The  ground  seed  is  used  in  making  the  linseed 
poultice. 

What  are  the  symptoms  of  iodism?  How  may  it  be 
prevented  while  the  use  of  the  iodide  is  continued? 

The  symptoms  of  iodism  are  anemia,  emaciation  and  mental 
■depression.  There  is  frontal  headache,  ptyalism,  a  saline  taste 
in  the  mouth,  dysphagia,  temporary  impotence,  and  an  erup- 
tion of  acne  on  the  face  and  limbs.  The  iodide  of  potash 
may  be  prescribed  in  combination  with  tincture  of  cinchona 
■or  with  Fowler's  solution,  which  prevents  the  iodic  eruption 
to  some  extent.  If  the  iodides  are  given  freely  diluted  in 
water  the  toxic  effects  are  less  likely  to  be  produced. 

Give  the  common  name  of  hydrastis  and  describe  its 
therapeutic  uses. 

Tlie  common  name  is  goldenseal.     It  is  used  chiefly  as  a 
stomach  tonic  and  antiperiodic,  a  mild  laxative  and  an  anti- 
24 


370      THERAPEUTICS  AND  MATERIA  MEDIC  A. 

septic.  It  is  of  value  in  catarrhal  inflammation  of  the  gastro- 
intestinal and  genito-urinary  tract  and  as  a  local  alterative 
and  antiseptic  application. 

Write  the  following  prescription  by  the  metric  system: 

Potassi  bicarb 8^  dr. 

Acidi  acetici 7  fl.  dr. 

Aquae 3  fl.  oz. 

Potassi  bicarb 13|5 

Acidi  acetici 25; 

Aquae 90 

What  are  the  possible  dangers  from  the  use  of  salol  in 
large  doses? 

Salol  breaks  up  in  the  body  into  salicylic  acid  and  carbolie 
acid.  It  is  apt  to  produce  the  symptoms  of  carbolic  acid 
poisoning. 

Give  the  medical  name  and  the  official  preparation  of 
lignum  vitae. 

Guaiacum.  The  official  preparations  are  the  tincture  of 
guaiac  and  the  ammoniated  tincture. 

What  are  the  therapeutic  uses  of  manganese? 

The  salts  of  manganese,  especially  the  permanganate  of 
potash,  are  used  in  anemia,  in  irregularities  of  menstruation, 
as  an  antidote  against  opium  or  morphine  in  the  stomach  and 
locally,  as  an  antiseptic  and  oxidizing  agent.  The  dioxide 
is  a  good  remedy  in  amenorrhea,  gastrodynia  and  pyrosis,  and 
in  the  form  of  an  ointment  for  many  skin  diseases. 

How  is  the  peroxide  of  hydrogen  prepared?  What  are 
its  therapeutic  uses? 

Bj  passing  CO,  through  water  containing  BaOo  in  suspen- 
sion, or  by  action  of  an  acid  on  BaOo.  The  U.  S.  P.  solution 
contains,  when  freshly  prepared,  3  per  cent,  of  the  pure 
dioxide,  corresponding  to  about  10  volumes  of  available 
oxygen.  This  preparation  is  a  non-toxic  antiseptic.  It  is 
employed  as  a  gargle  or  spray  in  quinsy,  croup,  diphtheria, 
scarlet  fever,  ozena,  and  for  the  purpose  of  cleansing  wounds. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      371 

It  may  possess  some  value  as  an  intestinal  antiseptic  on  ac- 
count of  the  fact  that  it  is  a  valuable  oxidizing  agent. 

What  are  the  therapeutic  uses  of  uva  ursae?  What  part 
of  this  plant  is  used  in  medicine? 

Bearberry  is  an  astringent  tonic,  and  is  feebly  diuretic. 
The  leaves  are  employed. 

What  is  the  common  name  of  oleum  morrhuae?  On 
what  physiologic  effect  does  its  therapeutic  use  depend? 

Cod-liver  oil.  The  action  of  cod-liver  oil  is  like  that  of 
any  other  fat  except  that  it  is  more  easily  assimilated  than 
any  member  of  the  class.  Its  beneficial  effects,  therefore,  are 
derived  solely  from  its  food  value. 

What  is  the  composition  of  linimentum  calcis?  For 
what  is  it  principally  used? 

Carron  oil  consists  of  equal  parts  of  lime-water  and  linseed 
oil.  and  is  employed  chiefly  in  burns. 

What  action  on  the  heart  has  valerian  in  full  doses? 
State  the  therapeutic  uses  of  valerian. 

In  full  doses  it  increases  the  action  of  the  heart  and  raises 
the  temperature.  The  oil  in  large  doses  lowers  the  blood 
pressure  and  slows  the  pulse.  Valerian  is  used  in  hysteria, 
for  the  flatulence  of  infants  and  nei'vous  subjects,  also  for 
coughs  of  nervous  type,  in  whooping  cough,  diabetes  insipi- 
dus and  in  delirium  with  vital  depression. 

Where  is  jalap  Indigenous?  What  part  of  it  Is  used  in 
medicine? 

Jalap  is  a  Mexican  plant.     The  root  is  used. 

Mention  the  salts  of  silver  used  in  medicine  and  give 
the  dose  of  each. 

Silver  nitrate,  dose  0.010  Gm.  (Vn  grain).  Silver  cyanide; 
this  is  not  used  in  medicine  except  in  the  preparation  of 
hydrocyanic  acid.     Silver  oxide,  dose  0.065  Gra.  (1  grain). 


372      THERAPEUTICS  AND  MATERIA  MEDICA. 

Describe  the  therapeutic  uses  of  (a)  water  and  (b)  min= 
eral  water. 

Cold  water  or  ice  has  many  external  applications  of  value 
in  the  treatment  of  disease.  As  a  wet  pack  it  is  used  in  ton- 
sillitis and  diphtheria.  The  cold  baths  and  the  cold  wet  pack 
are  the  best  methods  of  obtaining  an  antipyretic  effect  in 
fevers.  Cold  or  ice  water  is  applied  to  the  head  in  acute 
cerebral  congestion.  Locally  in  orchitis,  the  uterus  in  post- 
partum hemorrhage.  Hot  water  externally  is  most  effective 
in  reducing  local  congestion  and  setting  up  resolution  of 
local  inflammation.  The  hot  wet  pack  is  highly  esteemed  in 
inflammation  of  the  chest.  The  vaginal  hot-water  douche  is 
serviceable  in  catarrhal  conditions  of  the  vaginal  and  cervical 
mucous  membrane  and  congestive,  swollen  or  neuralgic  con- 
ditions of  the  ovaries,  tubes  and  adjacent  tissues.  Vapor  and 
Turkish  baths  are  used  in  chronic  kidney  disease  and  as 
diaphoretics  generally  wherever  a  diuretic  effect  is  desired. 
Internally,  water  is  of  value  as  a  diuretic,  and  if  hot  as  a. 
diaphoretic.  Mineral  waters  are  esteemed  most  highly  .when 
they  are  of  the  class  possessing  aperient  and  purgative  prop- 
erties. Depending  upon  the  composition  of  these  waters,  they 
may  be  of  value  in  chronic  rheumatism,  diabetes,  obesity, 
syphilis,  metallic  poisoning,  constipation,  etc. 

Where  is  the  cinnamon  tree  indigenous?  Mention  the 
active  principle  of  cinnamon  and  give  its  dose. 

Ceylon.  The  actve  principle  is  a  volatile  oil,  the  dose  of 
which  is  0.05  Cc.  (1  minim). 

What  therapeutic  uses  has  chloroform  other  than  as  an 
anesthetic? 

It  is  used  in  intestinal  colic  and  serous  diarrhea,  as  a  car- 
minative and  as  a  sedative  in  cases  of  obstinate  cough. 

What  is  the  dose  of  tincture  of  belladonna  and  what 
indications  show  that  its  physiologic  effect  has  been  ob= 
tained? 

Dose,  0.5   Cc.    (8  minims).     Medicinal  doses  quicken  the 


THERAPEUTICS  AND  MATERIA  MEDICA.      373 

pulse  and  large  doses  stimulate  respiration.  Dryness  of  the 
mucous  membrane  and  skin  and  dilatation  of  the  pupil  will 
indicate  that  the  physiologic  effect  has  been  reached. 

For  what  purposes  and  effects  is  strychnia  frequently 
used  in  formulae  for  cathartics? 

Strychnia  stimulates  the  muscular  coat  of  the  intestine, 
increasing  peristalsis,  and  thus  acts  as  a  purgative,  but  it  re- 
strains the  frequent  discharges  due  to  atony  of  the  bowels. 

What  effect  has  pilocarpus  on  (a)  the  heart,  (b)  the 
skin,  (c)  the  salivary  glands? 

(a)  Pilocarpus  acts  as  a  cardiac  depressant  by  stimulation 
of  the  vagus  ends;  (b)  it  causes  prompt  and  profuse  perspira- 
tion, and  (c)  salivation. 

What  is  the  source  from  which  eserine  is  obtained? 
How  and  for  what  purpose  is  eserine  principally  used? 

Eserine  is  one  of  the  alkaloids  of  physostigma.  It  is 
used  locally  in  solution  of  2  grains  to  the  ounce  in  the  eye 
to  contract  the  pupil  and  reduce  intra-ocular  tension.  Inter- 
nally it  is  efficient  in  constipation  due  to  torpor  of  the  bowel, 
in  which  condition  it  is  usually  combined  with  belladonna 
and  nux  vomica. 

Describe  the  therapeutic  uses  and  the  dangers  of  chloral 
hydrate.  How  does  a  toxic  dose  of  chloral  hydrate  affect 
body  temperature? 

Chloral  is  chiefly  used  to  promote  sleep  and  to  check 
spasms.  It  must  be  administered-  with  care  on  account  of  the 
danger  of  the  patient  becoming  addicted  to  the  chloral  habit. 
It  is  a  distinctly  dangerous  drug,  as  it  lowers  the  blood  pres- 
sure and  body  temperature.  Cardiac  and  respiratory  weak- 
ness are  contra-indications  to  its  use.  Toxic  doses  lower  body 
temperature. 

What  is  the  common  name  of  guaiacum?  What  are  the 
therapeutic  uses  of  guaiacum? 

Its  common  name  is  lignum  vita.     Guaiacum  is  diaphor- 


374      THERAPEUTICS  AND  MATERIA  MEDIC  A. 

etic,  expectorant  and  alterative,  also  laxative  and  purgative, 
according-  to  the  dose  administered. 

What  are  the  therapeutic  uses  of  limonis  succus? 

Lemon  juice  is  used  as  a  refrigerant  and  diuretic  mixture 
in  fever.  For  acidity  of  the  stomach  and  as  a  common 
remedy  in  obesity.  Locally  it  is  used  as  an  antipyretic,  anti- 
pruritic, and  as  a  gargle.  It  is  also  used  for  flavoring  pur- 
poses. 

Define  anthelmintic  and  name  the  remedies  of  this  class. 

Anthelmintics  are  agents  which  destroy  or  expel  worms 
inhabiting  the  intestinal  canal.  They  are  classed  according 
to  the  worm  against  which  they  are  each  most  efficient.  For 
thread  worms  the  principal  remedies  are  quassia,  alum,  sod- 
ium chloride,  lime-water,  and  the  vegetable  astringents.  For 
round  worm,  santonin,  spigelia.  chenopodium.  For  tape 
worm,  filix  mas,  kamala,  kousso,  pepo,  and  granatum.  The 
principal  vermifuges  are  the  purgatives,  castor  oil.  jalap, 
and  scammony. 

What  are  the  therapeutic  uses  of  resorcin? 

Resorcin  is  employed  as  an  antipyretic  and  antiseptic.  A 
3  per  cent,  solution  gives  good  results  in  ulcer  of  the  stom- 
ach, cancer  and  other  morbid  conditions.  It  is  also  used 
locally  as  a  remedy  in  skin  diseases. 

Name  the  official  preparation  and  state  the  therapeutic 
uses  of  santalum  album. 

Oil  of  santal  is  official.  It  is  extensively  used  in  chronic 
bronchitis  and  catarrhal  conditions  of  the  genito-urinary 
tract. 

How  is  collodium  made?  What  are  the  preparations  of 
collodium? 

Collodium  is  made  by  dissolving  4  parts  of  pyroxylin  in  75 
parts  of  ether  and  25  parts  of  alcohol.  Preparations  are  flex- 
ible collodium,  styptic  collodium  and  cantharidal  collodium. 
Collodium  is  used  as   a   protective   covering  for  superficial 


THERAPEUTICS  AND  MATERIA  MEDICA.      375 

burns,  ulcers,  wounds  and  slight  cuts.  Styptic  collodium  has 
many  uses  as  a  hemostatic  and  protective,  while  the  cantha- 
ridal  form  is  a  convenient  epispastic. 

Give  the  common  name  and  the  therapeutic  uses  of 
hematoxylon. 

Log-wood.  Log-wood  is  mildly  astringent,  its  properties 
depending  upon  the  tannin  contained  in  it.  It  is  not  irritat- 
ing, and  is  useful  in  diarrhea  and  hemorrhages  in  young 
children.  It  has  been  employed  as  a  hemostatic  in  bleeding 
of  the  lungs  and  hemorrhages  from  the  uterus  and  intestines, 
also  an  an  astringent  injection. 

On  what  physiologic  action  does  the  therapeutic  use  of 
elaterin  depend? 

Elaterin  is  the  most  powerful  of  the  hydragogue  cathar- 
tics, causing  profuse  watery  stools,  and  when  given  in  large 
doses  great  prostration  and  gastro-intestinal  irritation,  nausea 
and  vomiting. 

Name  three  drugs  incompatible  with  belladonna  and  two 
incompatible  with  pilocarpine. 

Tannin  and  the  hydroxides  of  potassium  and  sodium  are 
incompatible  with  belladonna,  and  are  also  incompatible 
with  pilocarpine,  as  are  the  salts  of  the  metals  generally. 

Give  the  usual  dose  of  creosote  and  tell  how  it  is  best 
administered. 

It  is  prescribed  in  doses  of  0.2  Cc.  (8  minims),  well  diluted 
in  wine  or  whiskey. 

Name  four  official  pills  and  give  the  principal  ingre- 
dients of  each. 

Pills  with  aloes  contain  purified  aloes  and  powdered  soap; 
pills  of  asafetida  contain  asafetida  and  powdered  soap ;  com- 
pound pills  of  iron  contain  myrrh,  carbonate  of  sodium,  sul- 
phate of  iron  and  .syrup;  compound  rhubarb  pills  contain 
rhubarb,  aloes,  myrrh  and  oil  of  peppermint. 


376      THERAPEUTICS  AND  MATERIA  ME  DIG  A. 

Define  tinctures,  extracts  and  ointments  and  tell  as  a 
rule  how  many  drops  of  a  tincture  are  in  a  fluid  dram. 

Tinctures  are  alcoholic  solutions  of  medicinal  substances, 
and  with  the  exception  of  tincture  of  iodine  are  made  from, 
non-volatile  bodies.  Extracts  are  solid  or  semi-solid  prepara- 
tions obtained  by  evaporating  solutions  of  vegetable  prin- 
ciples. Ointments  are  soft,  fatty  mixtures  of  drugs  with  a 
basis  of  lard,  petroleum  or  fixed  oils.  The  number  of  drops- 
to  a  fluid  dram  of  tinctures  varies  widely;  110  may  be  con- 
sidered an  average. 

Write  a  complete  prescription  containing  at  least  three 
drugs  for  acute  bronchitis  in  an  adult.     Use  no  abbrevia= 
tions. 
Jan.  1,  1910.  For  Mrs.  Watson.. 

R     Tinctura'  opii  caraphorata f  §  v 

Tinctura'  nucis  vomica^ f  §  ii 

Mistune  glycyrrhizae  compositce f  3iv 

M.  S. — Teaspoonful  every  four  hours.  John  Jones,  M.  D. 

In  the  treatment  of  syphilitic  node  or  gumma  state 
which  should  be  used,  a  mercurial  or  an  iodide,  and  give 
the  reason  thereof. 

In  the  treatment  of  the  tertiary  lesions  of  spyhilis  the 
iodides  and  mercury,  the  so-called  mixed  treatment,  are  often 
employed,  the  object  being  to  get  the  greatest  possible  alter- 
ative effect.  The  appearance  of  a  gumma,  especially  of  the 
nervous  system,  demands  energetic  drug  treatment.  Iodides 
should  be  given  in  the  largest  possible  doses,  and  mercury 
should  be  administered  by  inunction. 

Give  the  reason  which  would  determine  the  employment 
of  a  vegetable  or  a  mineral  astringent  in  acute  inflam= 
matory  conditions. 

Vegetable  astringents  check  secretion  and  hemorrhages  and 
cut  short  local  inflammation.     They  are  practically  non-toxic. 

Differentiate  the  condition  in  which  opium  and  hyoscine 
should  be  used  to  promote  sleep. 

Hyoscine  is  useful  as  a  hypnotic  in  children,  and  in  general 


THERAPEUTICS  AND  MATERIA  MEDICA.      377 

in  conditions  in  which  opium  is  contra-indicated.  Children 
are  particularly  susceptible  to  opium,  and  an  opium  habitue 
would  require  a  different  hypnotic. 

State  when  calomel  or  podophyllum  should  be  given  and 
give  the  reason  for  the  selection. 

Calomel  is  non-irritating,  and  has  also  a  diuretic  effect. 
Podophyllum  is  more  irritating  and  causes  more  griping, 
and  is  to  be  selected  in  cases  of  habitual  constipation. 

Name  the  coal=tar  products  used  to  reduce  temperature. 

There  are  many.  Those  in  general  use  are  antipyrine. 
acetanilide,  acetphenetidin. 

Describe  the  alkaloid,  strychnia,  and  give  a  test  for  de= 
termining  its  presence. 

Strychnia  is  an  alkaloid  derived  from  the  seed  of  strychnos 
nux-vomica,  a  tree  of  the  natural  order  Loganiaceae,  growing 
in  India  and  China.  Strychnia  and  its  salts  dissolve  without 
color  in  concentrated  sulphuric  acid,  but  on  adding  to  the 
solution  lead  peroxide  a  beautiful  blue  color  results,  passing 
into  violet,  then  red,  and  finally  yellow. 

What  are  the  derivatives  of  cinchona  and  their  doses? 

Cinchona  bark  contains  many  natural  alkaloids,  of  which  3 
are  official,  quinine,  cinchonine  and  cinchonidine.  The  sul- 
phates of  these  alkaloids  may  be  administered  in  doses  of 
0.250  Gm.  (4  grains). 

Describe  four  diuretics  and  give  the  dose  of  each. 

Potassium  citrate  occurs  in  transparent  crystals,  is  odor- 
less, of  cooling  saline  taste  and  a  neutral  reaction,  dose  1  Gm. 
(15  grains).  Sparteine  sulphate,  the  alkaloid  of  scoparius, 
occurs  in  white  prismatic  crystals  of  slightly  saline  and  bitter 
taste,  dose  0.010  Gm.  (Vt)  grain).  Digitalis  (elsewhere  de- 
scribed), dose  of  the  infusion,  8  Cc.  (2  fluidrachms).  Calo- 
mel, the  ftiild  chloride  of  mercury,  is  efficient  as  a  diuretic  iu. 
0.010  Gm.   (Vn  grain)  doses  every  hour. 


378      THERAPEUTICS  AND  MATERIA  MEDICA. 

How  does  a  lethal  dose  of  gelsemium  affect  the  system? 

In  toxic  doses  it  produces  vertigo,  diplopia,  drooped  eye- 
lids, dilated  pupils,  labored  respiration,  slow  and  feeble  heart, 
dropped  jaw.  staggering  gait,  extreme  muscle  weakness,  al- 
most complete  anesthesia,  and  death  by  asphyxia. 

Name  three  indications  for  the  use  of  opium. 

To  relieve  pain,  to  produce  sleep,  and  to  check  excessive  se- 
cretion, as  in  dysentery. 

How  does  opium  act  when  used  as  in  the  last  question? 

The  principal  action  of  opium  is  on  the  nervous  system, 
first  affecting  the  cerebral  convolutions,  which  are  briefly 
stimulated  and  soon  depressed :  next  the  perceptive  and  sen- 
sory centers  in  the  higher  brain  are  blunted  and  the  con- 
ductivity of  the  afferent  nerves  is  impaired.  The  hypnotic 
action  of  opium  is  believed  to  be  due  to  the  lessened  activity 
produced  by  the  drug  on  the  nerve  cells  and  the  consequently 
lessened  demand  for  blood.  Its  constipating  action  is  pro- 
duced by  stimulation  of  the  inhibitory  nerves  of  the  intestine 
through  the  splanchnic. 

What  are  the  therapeutic  uses  of  the  preparations  of 
bismuth? 

Locally  the  insoluble  bismuth  salts  are  used  in  acne  rosa- 
cea, stomatitis,  coryza.  gonorrhea  and  leucorrhea.  The  sub- 
nitrate  is  regarded  as  of  great  value  in  diarrhea  and  dysen- 
tery, in  disordered  digestion,  vomiting,  gastralgia.  and  gastric 
ulcer.  The  bismuth  nitrate  is  soluble  and  toxic,  and  is  not 
generally  used.  The  subcarbonate  and  the  subgallate  are  used 
in  the  same  class  of  cases  as  the  snbnitrate. 

How  would  you  distinguish  quinine  from  the  other  cin= 
chona  alkaloids? 

The  slight  solubility  of  the  sulphate  of  quinine  in  water 
distinguishes  this  alkaloid  from  other  cinchona  alkaloids. 


THERAPEUTICS  AND  MATERIA  MEDICA.      379 

Give  the  adult  dose  of  phosphorus,  solution  of  arsenous 
acid,  and  tincture  of  aconite. 

0.0005  Gm.  (7^28  grain)  ;  0.2  Cc.  (,3  minims j  ;  0.3  Cc. 
(5  minims). 

What  condition  of  the  eye  contra=indicates  the  use  of 
mydriatics? 

All  diseases  increasing  intra-ociilar  tension. 

Describe  the  physiologic  action  of  arsenic  and  name 
three  indications  for  its  use. 

In  therapeutic  doses,  with  the  exception  of  a  slight  increase 
in  the  pulse,  arsenic  exerts  very  little  influence  on  the  circu- 
lation. In  toxic  dose  it  causes  the  fall  of  blood-pressure.  In 
medicinal  dose  it  is  a  cerebro-spinal  stimulant,  but  in  toxic 
doses  it  paralyzes  the  spinal  cord,  especially  the  sensory  side. 
Small  doses  increase  the  appetite  and  stimulate  digestion. 
Toxic  doses  produce  violent  gastro-intestinal  inflammation. 
In  small  doses  it  diminishes  and  in  large  doses  increases  tissue 
waste.  In  concentrated  form  it  is  a  powerful  irritant  and 
escharotic.     It  is  indicated  in  anemia,  malaria  and  diabetes. 

For  what  medicinal  purposes  is  senna  used? 

It  is  used  as  a  laxative  in  habitual  constipation,  and  in 
larger  doses  as  a  cathartic. 

Write  a  prescription  for  an  ointment  containing  a  rube- 
facient and  at  least  one  other  constituent. 

Jan.  1,  1910.  For  John  Smith. 

R     Unguenti  hydrargyri  nitratis 5  iv 

Sulphurls 3  ii 

Creosoti gtt.  x 

Adipis f  5  i 

Ft.  unguentum f 3  i 

S. — Rub  in  well.  James  Jones.  M.  !>. 

What  is  the  usual  physiologic  action  of  an  astringent 
administered  internally? 

Astringents  are  agents  which  produce  contraction  of  muscle 
fiber  and  condensation  of  other  tissues.  They  lessen  secre- 
tions from  mucous  membranes. 


380      THERAPEUTICS  AND  MATERIA  MEDIGA. 

What  are  the  medicinal  uses  of  aminonia? 

Ammonia  is  employed  in  medicine  when  a  quick-acting 
heart  and  respiratory  stimulant  is  required.  It  is  also  used 
as  an  antacid  and  a  counter-irritant. 

What  are  the  therapeutic  uses  of  lime  (calcium)? 

Lime  in  its  unslaked  form  acts  upon  the  skin  as  an  irritant 
and  caustic;  if  inhaled  or  swallowed  it  may  produce  dan- 
gerous inflammation,  followed  by  ulceration.  In  weak  solu- 
tion it  has  a  sedative  and  an  astringent  effect,  both  locally 
and  internally,  and  acts  as  an  absorbant  and  antacid. 

For  what  pathologic  conditions  may  capsicum  be  used? 

It  is  an  excellent  stomachic  tonic  in  atonic  dyspepsia  and 
in  that  of  chronic  alcoholism  with  tremor  and  insomnia.  In 
acute  dipsomania  large  doses  are  effective  in  producing  sleep 
and  promoting  appetite.  Locally,  capsicum  plaster  is  a  mild 
counter-irritant. 

What  is  the  ordinary  relative  strength  of  a  tincture  to 
a  fluid  extract  of  the  same  drug? 

With  fluid  extracts  a  cubic  centimeter  represents  the  medic- 
inal powers  of  1  gramme  of  the  drug.  Tinctures  are  divided 
into  two  classes.  A  uniform  strength  of  10  per  cent,  has  been 
adopted  by  the  new  pharmacopoeeia  for  the  tinctures  of  potent 
drugs.    Other  tinctures  have  a  strength  of  20  per  cent. 

Name  three  agents  which  are  used  to  promote  menstru- 
ation. 

Potassium  permanganate,  purgatives,  as  castor  oil,  and 
ergot. 

How  do  the  preparations  of  gentian  affect  the  human 
system  and  in  what  conditions  are  they  indicated? 

Gentian  is  used  exclusively  as  a  bitter  tonic.  In  atonic 
dyspepsia  it  increases  the  appetite  and  stimulates  digestion. 

The  dose  of  medicine  given  by  the  mouth  being  i  grain» 


THERAPEUTICS  AND  MATERIA  ME  DIG  A.      381 

what  would  be  the  equivalent  dose  for  hypodermic  use  and 
what  for  administration  by  the  rectum? 

For  hypodermic  injection  the  dose  should  be  %  or  %  of 
that  used  by  the  mouth.    By  the  rectum  V4  of  the  same. 

How  should  a  case  of  poisoning  with  chloral  hydrate  be 
treated? 

The  patient  should  be  aroused  by  friction,  douches,  etc., 
but  must  not  be  made  to  walk,  as  in  opium  poisoning,  on  ac- 
count of  heart  failure.  Cardiac  and  respiratory  stimulants 
should  be  given  freely,  as  ammonia,  atropine  and  strychnine. 
Artificial  respiration  should  be  resorted  to  early,  before  the 
development  of  asphyxia. 

In  what  conditions  may  cathartics  be  useful  in  the  treat= 
ment  of  diarrhea  or  dysentery? 

Cathartics  are  useful  in  the  treatment  of  diarrhea  and  dys- 
entery, especially  early  in  the  course  of  this  condition,  in  the 
case  of  diarrhea  for  the  purpose  of  removing  offending  ma- 
terial, a.s  indigestible  food,  discharges,  bacteria,  etc. 

Define  a  laxative,  a  saline  purgative,  a  drastic  purgative, 
a  hydragogue  purgative  and  a  cholagogue  purgative,  with 
an  example  of  each. 

Laxatives  are  drugs  which  excite  moderate  peristalsis  and 
produce  soft  stools  without  irritation,  as  sulphur.  Saline 
purgatives  include  the  neutral  salts  of  metals,  of  the  alkalies 
or  alkaline  earths;  they  stimulate  the  intestinal  glands  to 
increased  secretions  and  produce  a  copious  evacuation,  as 
Epsom  salts.  A  drastic  purgative  produces  violent  peri- 
stalsis and  watery  stools,  with  much  griping  pain  and  tenes- 
mus; in  large  doses  irritant  poisoning  results,  as  jalap.  Hy- 
dragogue purgatives  are  those  which  remove  a  large  quantity 
of  water  from  the  vessels,  as  elaterium.  Cholagogue  purga- 
tives stimulate  the  discharge  of  bile  and  produce  free  purga- 
tion, as  podophyllin. 

Would  you  administer  charcoal  internally,  and  if  so  in 
what  dose  and  for  what  purpose? 

Tt  may  be  given  with  advantage  in  chronic  gastric  catarrh, 


382      THERAPEUTICS  AND  MATERIA  MEDICA. 

cancer,  intestinal  dyspepsia  and  diarrhea  when  flatulence  is  a 
prominent  symptom.    Dose  is  1  Gm.  (15  grains). 

What  are  the  physiologic  effects  of  gelsemium? 

Medicinal  doses  do  not  affect  the  circulation.  Toxic  doses 
depress  the  heart.  It  is  a  marked  depressant  to  the  spinal 
cord,  and  in  toxic  doses  produces  paralysis.  The  drug  kills 
by  paralyzing  the  respiratory  center.  Locally  the  drug 
causes  dilatation  of  the  pupil,  probably  from  paralysis  of  the 
oculo-motor  nerve. 

Describe  the  therapeutic  uses  of  jalap  and  state  how  it 
differs  in  effect  from  aloes. 

In  moderate  dose  jalap  acts  as  a  hydragogue  cathartic,  pro- 
ducing copious  watery  discharges.  It  is  best  given  in  the 
form  of  compound  jalap  powder  in  conditions  of  general 
dropsy,  and  should  never  be  employed  in  simple  constipation. 
Aloes  is  a  cholagogiie  cathartic,  stimulating  the  discharge  of 
bile. 

Name  two  remedies  which  are  commonly  used  to  pro= 
mote  intestinal  peristalsis. 

Belladonna  and  nux  vomica. 

What  are  the  therapeutic  uses  of  guaiac? 

Used  locally  and  internally  in  acute  bronchitis ;  often  pre- 
scribed in  chronic  rheumatism,  gout,  sciatica  and  lumbago. 

Name  the  official  bromides. 

The  bromides  of  potassium,  sodium,  lithium,  ammonium, 
strontium  and  zinc. 

Describe  the  therapeutic  uses  of  ox=gall. 

It  is  a  tonic,  antiseptic  and  purgative,  stimulating  the  ab- 
sorptive powers  of  the  mucous  membrane.  It  is  frequently 
used  as  a  laxative  in  constipation. 

Where  does  buckthorn  grow?  Give  the  official  prepara^ 
tion  and  dose. 

In  Europe.  Fluidextract  of  frangula.  Dose  1  Cc.  (l.S 
minims). 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      383 

What  are  the  therapeutic  uses  of  gelsemium? 

It  is  indicated  in  all  conditions  of  exalted  nerve  function, 
and  contra-indicated  whenever  the  heart  is  weak.  It  is  espec- 
ially usefnl  in  cerebro-spinal  meningitis,  mania,  persistent 
insomnia,  neuralgia,  dysmenorrhea,  incontinence  of  urine,  ir- 
ritation of  the  bladder,  spasmodic  coughs  and  remittent  or 
typho-malarial  fevers. 

What  is  the  purgative  dose  of  acetate  of  potassium? 

Two  to  four  drachms. 

What  is  the  common  name  and  therapeutic  use  of 
piumbi  acetatis? 

Sugar  of  lead.  It  is  a  component  of  the  mixture  of  lead 
water  and  laudanum,  which  is  employed  in  bruises  and  in- 
flammatory swellings  where  the  skin  is  not  broken.  It  is 
used  in  solution  as  a  lotion  in  skin  disea.ses  and  prui-itus.  and 
is  employed  as  an  astringent  in  diarrhea. 

How  do  official  waters,  e.  g.  aqua  camphorae,  differ 
from  solutions,  e.  g.  liquor  calcis? 

Waters  are  aqueous  solutions  of  volatile  substances;  liquors 
are  aqueous  solutions  of  non-volatile  substances. 

How  do  potassium  acetate  and  potassium  bitartrate 
compare  as  diuretics  and  purgatives? 

The  acetate  is  the  more  certain  diuretic:  the  bitartrate  is 
the  more  active  cathartic. 

Give  the  common  name  and  the  official  preparations  of 
prunus  Virginiana. 

Wild  chei'ry.  The  official  i)rt*paratioiis  ai-t^  thf  fluid  t'x- 
tract,  infusion  and  syruji. 

On  what  chemical  change  in  the  intestinal  tract  does 
the  purgative  action  of  castor  oil  depend? 

The  oil  is  decomposed  by  tlie  pancreatic  juice,  setting  free 
ricinoleic  acid,  which  produces  purgation  by  a  mildly  in-itant 
action  on  the  bowels,  stimulating  the  glands  and  imisiMilar 
roat,  but  not  the  liver. 


:384      THERAPEUTICS  AND  MATERIA  MEDIC  A.  ' 

What  are  the  therapeutic  uses  of  acetic  acid? 

Used  internally  as  a  mild  refrigerant  and  antiscorbutic, 
and  as  an  antidote  in  poisoning  by  alkalies,  such  as  ammonia. 
Locally  is  it  used  to  check  hemorrhages  and  as  an  escharotic. 

What  is  the  proportion  of  mercury  in  blue  pill?  What 
is  the  dose  of  blue  pill? 

It  contains  33  per  cent,  of  mercury.    Dose  1  to  20  grains. 

What  effect  has  benzoin  on  the  urine?  Name  the  prep= 
arations  of  benzoin. 

It  renders  the  urine  acid  and  increases  its  quantity.  The 
preparations  of  benzoin  are  adeps  benzoinatus,  tinctura  ben- 
zoini,  tinct.  benzoini  composita,  acidum  benzoicum,  ammonii 
benzoas,  lithii  benzoas,  sodii  benzoas. 

What  are  the  alkaloids  of  pilocarpus  and  how  do  they 
compare  in  physiologic  effect? 

The  alkaloids  of  pilocarpus  are  pilocarpine ;  jaborine,  an- 
tagonistic to  pilocarpine  in  action ;  pilocarpidine,  analogous 
to  pilocarpine ;  and  jaboridine,  which  is  analogous  to  jaborine. 

What  is  the  source  of  camphor  and  what  is  the  dose  of 
spiritus  camphorae? 

Camphor  is  a  stearopten  obtained  from  the  cinnamomum 
camphora,  a  tree  of  the  natural  order  Lauracece  (indigenous 
to  China  and  Japan),  purified  by  sublimation.  Dose  of  the 
spirit  1  Cc.  (15  minims). 

Give  the  common  name  and  the  therapeutic  uses  of 
potassium  bitartrate. 

Cream  of  tartar.  It  is  an  agreeable  laxative,  and  also  is 
used  as  a  diuretic  in  infusion  of  juniper  in  general  cardiac 
•dropsy. 

Give  the  source  and  preparations  of  gum  arabic. 

Acacia,  gum  arabic,  is  a  gummy  exudation  of  acacia  Sen- 
egal, a  small  tree  native  in  Africa.  Its  preparations  are  the 
syrup  and  mucilage.  It  enters  also  into  the  composition  of 
official  troches,  etc. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      385 

Mention  the  therapeutic  uses  of  nitric  acid. 

It  is  locally  a  powerful  escharotic,  and  is  used  internally  in 
dilute  form  in  bilious  affections.  It  lessens  phosphatic  de- 
posits and  acts  as  an  astringent  to  the  system,  diminishing 
expectoration  in  bronchorrhea  and  phthisis. 

Give  the  physiological  action  and  the  therapeutic  uses  of 
sarsaparilla. 

It  is  doubtful  if  it  possesses  any  physiologic  action.  Some, 
however,  claim  it  to  be  diuretic,  diaphoretic,  tonic  and  alter- 
ative. Its  chief  value  is  as  an  excipient  for  administering 
potassium  iodide  and  mercuric  chloride  in  syphilis. 

Describe  and  give  the  indications  for  the  uses  of  cardiac 
sedatives,  with  an  example. 

Cardiac  sedatives  are  drugs  which  are  used  to  decrease  the 
activity  of  the  circulation.  The  indications  for  their  use  are 
increased  arterial  excitement,  sthenic  fevers  and  severe  local 
inflammation.  Aconite  is  an  example  of  such  a  drug.  It 
reduces  very  markedly  the  rate  of  the  pulse  and  the  arterial 
pressure. 

Describe  the  physiologic  action  of  antipyrine  in  medici= 
nal  doses  on  the  circulation  and  temperature. 

After  the  ingestion  of  a  full  medicinal  dose  there  is  a  stim- 
ulant stage,  in  which  the  heart 's  activity  is  increased :  this  is 
soon  followed  by  profuse  sweating,  coolness  of  the  surface, 
slowed  pulse,  considerable  depression,  and.  if  fever  be  present, 
'by  lowered  temperature.  In  health  it  has  very  slight  anti- 
pyretic effect.  It  i-ai.ses  the  arterial  tension  and  blood  pres- 
sure. 

How  do  digitalis  and  belladonna  act  in  increasing  blood 
pressure? 

Digitalis  increases  blood  pressure  by  its  stimulating  effect 
on  the  heart  and  by  contraction  of  the  arterioles,  resulting 
indirectly  from  stimulation  of  the  vasomotor  center,  and  di- 
rectlv  from  the  action  of  the  drug  on  the  vessel  wall.     The 


386      THEBAPEVTICS  AND  MATERIA  MEDICA. 

increased  blood-pressure  produced  by  belladonna  is  due  to 
stimulation  of  the  vasomotor  centers  and  the  heart  itself. 

Name  a  vasomotor  stimulant,  a  vasomotor  depressant 
and  describe  the  physiologic  action  of  each. 

Belladonna  is  a  vasomotor  stimulant;  it  quickens  the  pulse 
and  raises  arterial  pressure.  The  increased  blood-pressure 
is  due  to  stimulation  of  the  vasomotor  center  and  the  heart 
itself.  Toxic  doses  paralyze  the  heart ;  large  doses  stimulate 
the  respiratory  center;  toxic  doses  paralyze  it;  large  doses 
stimulate  the  brain  and  spinal  cord  and  act  as  a  depressant 
to  the  motor  and  sensory  nerves;  it  lessens  neai-ly  all  of  the 
secretions  except  that  of  the  kidney;  it  dilates  the  pupil  by 
paralyzing  the  peripheral  ends  of  the  oculo-motor  nerves, 
and  by  stimulating  the  ends  of  the  sympathetic.  Veratrum 
viride  is  a  vasomotor  depressant;  it  lessens  in  a  marked  de- 
gree the  force  and  rate  of  the  cardiac  pulsation ;  the  lowered 
arterial  tension  results  from  depression  of  the  vasomotor  cen- 
ter and  of  the  heart  itself;  the  slowing  of  the  pulse  from 
stimulation  of  the  inhibitory  nerves  of  the  heart  and  from 
weakening  of  the  cardiac  muscles.  Large  doses  depress  the 
respiratory  center,  the  spinal  cord  and  peripheral  nerves  and 
muscles. 

Give  the  theory  of  the  alkaline  treatment  of  rheuma= 
tism. 

The  alkaline  treatment  of  rheumatism  by  the  administra- 
tion of  potassium  acetate,  citrate,  etc.,  was  in  general  use 
before  the  introduction  of  the  salicylates.  Wood  states  that 
the  alkalies  do  good  in  rheumatism  by  lowering  arterial  ac- 
tion, by  favoring  oxidation  and  elimination  of  partially  effete 
products,  and  by  neutralizing  excessive  acidity. 

What  is  incompatibility  in  medicine,  and  what  are  the 
different  kinds  of  incompatibles?  Given  an  example  of 
each. 

Incompatibility  in  medicine  signifies  that  a  combination  is 
not    suitable    for    administration.      Incompatibility    may    be- 


THERAPEUTICS  AND  MATERIA  MEDICA.      387 

chemical,  pharmaceutical  or  therapeutic,  according  as  the 
prescribed  combination  results  in  chemical  decomposition, 
physical  disassociation  or  antagonistic  action.  An  example 
of  chemical  incompatibility  is  seen  in  the  prescribing  of  qui- 
nine sulphate  with  potassium  acetate,  resulting  in  a  volu- 
minous precipitate  of  quinine  acetate.  An  instance  of  phar- 
maceutical incompatibility  is  the  addition  of  an  acid  to  a 
({uinine  and  liquorice  mixture,  resulting  in  precipitation  of 
the  glycyrrhizin,  relied  on  to  cover  the  taste  of  the  quinine. 
Therapeutic  incompatibility  arises  when  two  agents  mixed 
together  oppose  each  other  in  their  action,  for  instance,  bella- 
donna and  physo stigma. 

Describe  the  physiologic  action  of  salicylic  acid. 

Salicylic  acid  is  a  powerful  antipyretic  and  antiseptic.  In 
small  doses  it  stimulates  the  stomach,  heart  and  respiration, 
but  moderate  quantities  derange  the  stomach,  causing  nausea 
and  vomiting,  while  large  doses  depress  the  heart's  action 
and  the  respiration,  lower  the  arterial  tension,  relax  the  ves- 
sels and  produce  free  perspiration. 

Name  the  therapeutic  uses  of  apomorphia  and  state  how 
codeia  differs  in  its  physiologic  action  from  morphia. 

Apomorphia  is  a  valuable  emetic  and  a  useful  expectorant 
in  the  dry  stage  of  acute  bronchiti.s,  and  in  chronic  bronchitis 
when  the  expectoration  is  viscid  and  scanty.  While  codeia 
possesses  but  feeble  hypnotic  powers,  it  exerts  a  sedative  in- 
fluence similar  to  morphine;  it  is  at  times  much  better  borne 
by  patients  than  morphine,  but  is  regarded  as  less  reliable. 

Enumerate  the  symptoms  arising  from  a  toxic  dose  of 
digitalis. 

Digitalis  poisoning  is  characterized  by  obstinate  voTiiiting, 
diarrhea,  headache,  severe  pain  in  the  back  and  limbs  and  a 
very  .slow,  full  pulse,  which,  when  the  patient  sits  up.  may 
beeonio  rapid  and  feeble.  Later,  even  in  recumboiicy.  the 
pnlse  becomes  rapid,  thready  and  irregular,  the  surface  cold, 
the  urine  suppressed  and  the  itiiml  stuporous.     Tntclligence, 


388      THERAPEUTICS  AND  MATERIA  MEDICA. 

however,  is  not  lost  until  shortly  before  death.     Occasionally 
convulsions  develop  duringr  the  last  stage. 

What  are  the  therapeutic  uses  of  tartar  emetic? 

It  is  employed  as  an  emetic,  diaphoretic,  sedative,  expecto- 
rant, cardiac  depressant  and  counter-irritant. 

Describe  cantharis  and  name  three  official  preparations. 

Cantharis  is  the  dried  body  of  the  beetle.  Cantharis  vesiea- 
toria,  found  chiefly  in  the  south  of  Europe.  The  active  prin- 
ciple is  cantharidin.  Ceratum  cantharidis.  collodium  can- 
tharidatum.  tinctura  cantharidis. 

By  what  rule  would  you  determine  the  dose  of  any  medi= 
cine  for  a  child? 

Young's  rule  will  be  found  the  most  convenient.  Add  12 
to  the  age  and  divide  by  the  age,  to  get  the  denominator  of  a 
fraction,  the  numerator  of  which  is  1 ;  thus,  for  a  child  2 
years  old,  2  plus  12  divided  by  2  equals  7.  and  the  dose  is  1-7 
of  that  for  an  adult. 

Name  ten  official  preparations  of  mercury.  Name  four 
alkaloids  of  opium. 

Hydrargyrum  cum  creta.  massa  hydrargyri,  unguentum 
hydrarygri,  emplastrum  hydrargyri.  hydrargyri  chloridum 
mite,  hydrargyrum  ammoniatum.  unguentum  hydrargyri 
ammoniati,  hydrargyri  oxidum  fiavum.  unguentum  hydrar- 
gyri oxidi  fiavi.  hydrargyri  oxidum  rubrum.  Four  alka- 
loids of  opium  are  morphine,  codeine,  thebaine  and  narcotine. 

Give  the  source  and  dose  of  picrotoxin.  creosote  and  pix 
liquida. 

Picrotoxin  is  a  neutral  principle  derived  from  cocculus 
indicus,  dose  1-100  to  1-20  grain.  Creosote  is  a  product  ob- 
tained by  distillation  of  wood-tar,  dose  0.2  Cc.  (3  minims). 
Pix  liquida.  tar,  is  an  oleoresin  obtained  from  the  destructive 
distillation  of  certain  species  of  Pinus;  the  dose  is  0.500  Gm. 
(71/2  grains). 


THERAPEUTICS  AND  MATERIA  MEDICA.      389 

What  are  the  principal  therapeutic  uses  of  the  prepara= 
tions  of  mercury? 

The  plaster  of  mercury  is  used  as  an  absorbent  and  counter- 
irritant  over  chronic  inflammatory  swelling,  glandular  en- 
largements, syphilitic  nodes,  etc.  Mercurial  ointment  and 
the  oleate  of  mercury  are  used  for  the  same  purposes  as  the 
plaster:  they  are  also  entensively  employed  in  the  treatment 
of  syphilis  by  inunction.  Blue  mass  is  used  as  a  cholagogue, 
laxative  and  diuretic.  Ammoniated  mercury  is  used  exter- 
nally as  a  stimulant  or  parasiticide.  The  chloride  of  mer- 
cury is  an  antiseptic,  anti-parasitic,  anti-syphilitic  ab- 
sorbent, and  tonic.  The  mild  chloride,  calomel,  is  used 
internally  as  an  anti-syphilitic,  as  a  laxative,  as  a  gastric 
sedative,  a  cholagogue  and  a  diuretic,  and  externally  as  a 
stimulant  and  desiccant.  Mercury  and  chalk  is  used  in  the 
same  class  of  cases  as  calomel.  The  yellow  iodide  is  fre- 
quently used  as  a  substitute  for  the  chloride,  as  is  the  red 
iodide.  The  nitrate  is  used  externally  as  a  powerful  caustic. 
The  oxide  is  used  externally  for  its  stimulant  and  alterative 
effect.  The  yellow  sulphate,  turpeth  mineral,  is  sometimes 
employed  as  a  stimulating  emetic  for  children,  but  it  is  dis- 
tinctly poisonous. 

State  the  contra=indications  to  the  use  of  quinine. 

It  is  contra-indicated  in  acute  inflammatory  affections  of 
the  brain,  eyes  and  ears. 

In  what  form  would  you  prescribe  eucalyptus  and  in 
what  doses?     Whence  is  eucalyptus  obtained. 

Eucalyptus  is  derived  from  the  leaves  of  the  tree  Euca- 
lyptus globulus,  a  native  of  Australia.  It  may  be  prescribed 
in  doses  of  2  Cc.  (30  minims)  of  the  fluid  extract  or  in  doses 
of  0.5  Ce.  (8  minims)  of  the  oil  in  capsules  or  emulsion. 

In  what  strength  would  you  use  solutions  of  nitrate  of 
silver,  borax,  permanganate  of  potash,  bichloride  of  mer- 
cury and  creolin  for  injection  into  the  bladder? 

Silvci'  nitralo.  1  gi-ain  in  4  ounces  of  water;  borax.  10  grains 


390      THERAPEUTICS  AND  MATERIA  MEDIC  A. 

to  the  ounce;  permanganate  of  potassium,  20  grains  to  the 
pint;  bichloride  of  mercury,  1  to  8000;  creolin,  i/^  to  1  per 
cent. 

Name  six  drugs  containing  large  quantities  of  tannic 
acid. 

Galla,  catechu,  hamamelis,  kino,  granatum,  hematoxylon. 

•  Name  four  drugs  incompatible  with  iodide  of  potassium, 
two  with  atropine  and  one  with  antipyrine. 

Potassium  iodide  decomposes  most  of  the  metallic  salts. 
The  following  four  drugs  are  examples  of  this  incompati- 
bility :  Sulphate  of  quinine,  sulphate  of  iron,  acetate  of  lead, 
oxide  of  zinc.  Physostigmine  and  aconite  are  incompatible 
with  atropine.     Tannic  acid  is  incompatible  with  antipyrine. 

Give  the  physiologic  action  of  ergot  and  mention  its 
therapeutic  uses. 

Ergot  is  a  motor  excitant  and  a  vascular  contractor.  It  is 
also  hemostatic  and  anhydrotie,  emmenagogue  and  oxytocic. 
It  increases  the  functional  activity  of  the  spinal  cord,  it  stim- 
ulates the  vasomotor  center,  raises  the  blood-pressure,  pro- 
duces contraction  of  unstriped  muscle  fiber,  reduces  the  cali- 
ber of  the  arterioles,  depresses  the  motor  ganglia  of  the  heart 
and  causes  a  slower  and  weaker  pulsation. 

Ergot  is  used  to  promote  uterine  contractions  in  labor,  in 
amenorrhea  due  to  plethora  and  in  the  atomic  form  of  sper- 
matorrhea. It  is  useful  in  catarrhal  inflammations  of  the 
mucous  membranes  generall.y.  It  is  an  excellent  remedy  in 
chronic  diarrhea  and  dysentery,  in  hemorrhages  of  arterial 
type,  in  headache  and  migraine  of  congestive  form,  in  mye- 
litis and  tabes  and  chronic  nervous  diseases.  It  is  also  used 
locally  in  hemorrhages. 

Name  four  drugs  used  in  the  treatment  of  bronchorrhea 
and  explain  their  action. 

Eucalyptus  for  its  expectorant  effect.  Lead  acetate  for  its 
astringent  effect  to  restrict  secretions.  Quinine  and  arsenic 
as  valuable  tonics  and  restoratives. 


THERAPEUTICS  AND  MATERIA  MEDICA.      391 

What  is  the  physiologic  action  of  rhubarb  in  dose  of  i 
to  5  grains?     In  dose  of  30  to  60  grains? 

In  small  doses  its  action  is  that  of  a  gastric  tonic  and  an 
intestinal  astringent.  In  larger  doses  its  cathartic  action 
prevails,  producing  in  6  to  8  hours  copious  yellow  stools  with 
some  griping  and  considerable  hepatic  stimulation. 

For  what  purposes  is  diaphoresis  produced?  Name 
three  diaphoretics. 

Diaphoretics  are  employed  in  medicine  to  fulfil  the  follow- 
ing indications:  (1)  to  arrest  forming  diseases  of  not  very 
severe  type,  as  in  general  cold  and  suppressed  menstruation; 
(2)  to  favor  absorption,  as  in  dropsy;  (3)  to  aid  in  the  sub- 
sidence of  diseases  which  naturally  pass  off  in  a  sweat,  as 
malaria:  (4)  to  eliminate  noxious  materials  from  the  blood. 
Three  excellent  diaphoretics  are  pilocarpus,  spirit  of  nitrous 
ether  and  Dover's  powder. 

What  is  the  source  and  what  are  the  therapeutic  uses  of 
picrotoxin? 

[*icrotoxin  is  a  poisonous  neutral  principle  obtained  from 
the  seeds  of  cocculus  indicus,  used  in  the  night  sweats  of 
phthi.sis  and  in  the  form  of  an  ointment  as  an  anti-parasitic. 

Give  the  chemical  name  and  the  dose  of  (a)  Epsom 
salts,  (b)  Rochelle  salts,  (c)  Glauber's  salts. 

(a)  ^Magnesium  sulphate,  dose  16  (Jm.  (240  grains)  ;  (b) 
potassium  and  sodium  tartrate,  dose  8  Gm.  (120  grains) ;  (c) 
sodium  sulphate,  dose  16  CUn.  (240  grains). 

Describe  hypodermoclysis  and  state  the  circumstances 
under  which  it  is  practiced  as  a  therapeutic  measure. 

Hypodermoclysis  is  the  introduction  into  the  subcutaneous 
tissue  of  fluids  in  large  quantity.  It  is  indicated  to  replace 
the  fluid  lost  through  excessive  purging  or  hemorrhage.  It 
may  also  be  used  to  wash  from  the  body  certain  impurities 
circulating  in  the  blood  and  lymph;  in  other  instances  it  jnay 
be  used  to  supply  the  body  with  liquid  when  the  stomach  will 
not   permit  drinks  to  be  swallowed,   as  in   gastric   ulcer  or 


392      THERAPEUTICS  AND  MATERIA  MEDICA. 

abdominal  operations.  Normal  saline  solution  is  used  for 
such  injections.  The  sterilized  liquid  is  placed  in  a  proper 
vessel  ^dlich  is  absolutely  aseptic,  and  to  which  air  gains  ac- 
cess only  by  means  of  a  glass  tube  filled  with  sterilized  cotton ; 
from  the  lower  part  of  the  vessel  a  rubber  tube  leads,  to 
which  is  attached  a  canula  carefully  sterilized.  The  skin 
over  the  place  where  the  liquid  is  to  enter  is  to  be  rendered 
sterile.  The  trocar  is  then  inserted  into  the  subcutaneous 
tissue  of  the  abdomen  or  thigh  and  the  solution  allowed  to  flow 
at  the  rate  of  1  dram  to  each  pound  of  body  weight  in  15 
minutes.  The  pressure  is  obtained  by  raising  the  container  a 
few  feet. 

Define  galactagogue  and  sialagogue  and  give  an  example 
of  each. 

A  galactagogue  is  an  agent  which  increases  the  secretion  of 
milk,  example  pilocarpus.  A  sialagogue  increases  the  secre- 
tion and  flow  of  saliva  and  buccal  mucus,  example  mercury. 

By  what  process  and  from  what  source  is  sugar  of  milk 
principally  obtained? 

It  is  a  crystalline  sugar  obtained  from  the  whey  of  cows'" 
milk  by  evaporation  and  recrystallization. 

State  the  source  and  give  the  uses  of  saccharin. 

It  is  derived  from  coal  tar.  It  is  about  500  times  sweeter 
than  sugar  and  is  used  as  a  substitute  for  sugar  in  the  food 
of  diabetics  and  subjects  of  liver  disease  and  corpulence. 

Describe  the  preparation  of  lime  water.  Give  the  oflfi= 
cial  name  and  the  adult  dose. 

Liquor  calcis  may  be  given  to  an  adult  in  average  doses  of 
16  Cc.  (4  fluidrachms) .  It  may  be  prepared  by  pouring  2 
quarts  of  hot  water  over  fresh  unslaked  lime  the  size  of  a 
walnut;  stir  till  slaked,  let  it  stand  until  clear  and  bottle. 

Give  the  source,  the  physiologic  action  and  the  thera= 
peutic  uses  of  oleum  ricini. 

Castor  oil  is  a  fixed  oil  expressed  from  the  seeds  of  ricinus. 


THERAPEUTICS  AND  MATERIA  ME  DIG  A.      393 

communis.  It  acts  as  a  mild,  but  rather  slow  purgative,  pro- 
ducing without  irritation  copious  semi-liquid  stools.  It  does 
not  increase  the  tlow  of  bile  nor  to  a  great  extent  the  secre- 
tions of  the  intestinal  canal,  but  excites  catharsis  by  stimu- 
lating the  muscular  coat  of  the  bowel.  It  is  useful  in  acute 
inflammatory  affection  of  the  bowel  and  as  a  laxative  in  preg- 
nancy, anal  fissure  and  painful  hemorrhoids. 

What  are  the  medicinal  uses  of  potassium  chlorate? 

It  is  an  excellent  local  application  in  inflammatoiy  condi- 
tions of  the  mouth  and  throat,  being  valuable  in  the  various 
forms  of  stomatitis,  in  acute  pharyngitis,  in  diphtheria  and 
scarlet  fever. 

How  should  poisoning  by  coal  gas  be  treated? 

Antidotes,  chlorine  water  as  a  spray,  inhaled.  Antag<i- 
nists,  oxygen  by  inhalation  4  or  5  quarts.  Ammonia  vapor 
inhaled.  Galvanism,  by  interrupted  current  to  extremities. 
Artificial  respiration,  to  be  maintained  steadily  for  hours. 
Rhj^thmic  traction  of  the  tongue.  Fresh  air  in  plenty ;  open 
all  doors  and  windows.  Coffee,  black,  a  pint  as  enema. 
Venesection  followed  by  normal  saline  transfusion  may  be  of 
service.  Douche,  alternately  cold  and  warm,  to  head  and 
chest.  Horizontal  position,  clothing  removed.  Alcohol  mod- 
erately by  mouth  and  rectum.  Catheter  may  be  required  in 
prolonged  ca.ses.  Subsequently  a  warm  bed,  heat  applied  to 
the  body  and  limbs,  open  windows,  perfect  quiet.  Condy's 
fluid  about  the  room,  stimulants  sparingly,  cold  acid  drinks 
freely. 

Write  a  prescription  for  a  cough  mixture  containing 
muriate  of  ammonia  and  an  opiate,  giving  adult  dose. 

Jan.  1.  inio.  For  .Joskph  \Vii>t>N. 

R     Amnionii  cliloridi 3^ 

Tr.  opii  catnpli f3v 

Syr.  pruni  virg f §  iv 

M.  S. — f3i  ev*ry  four  lioiirs. 

.loHKI'H  .loNK-.   M.    I). 


394      THERAPEUTICS  AND  MATERIA   MEDICA. 

What  are  the  therapeutic  uses  of  podophyllin? 

It  is  an  excellent  laxative  in  constipation  associated  with 
hepatic  congestion.  It  tends  to  produce  griping  and  is  usu- 
ally given  with  small  doses  of  belladonna  or  hyoscyamus. 

What  is  the  dose  of  Fowler's  solution  and  what  precau= 
tions  should  be  observed  in  its  administration? 

The  dose  is  0.2  Cc.  (3  minims).  Potter  advises  that  full 
doses  of  the  solution  should  be  taken  at  first,  and  always  im- 
mediately after  food;  the  dose  should  then  be  gradually  re- 
duced. Susceptible  persons  often  tolerate  it  better  if  a  few 
drops  of  laudanum  are  administered  with  each  dose.  Swell- 
ing beneath  the  eyes  is  an  indication  of  the  physiologic  limit 
for  the  employment  of  the  drug. 

From  what  part  of  the  colchicum  plant  is  the  active 
principle  obtained? 

From  the  corm  and  seed. 

What  injurious  effect  is  liable  to  follow  the  prolonged 
internal  use  of  the  preparation  of  silver? 

Argyria.  The  first  sign  of  this  condition  is  a  slate-colored 
line  along  the  margin  of  the  gum  with  some  inflammatory 
swelling.  Subsequently  grayish  patches  appear  on  various 
parts  of  the  skin  and  mucous  membrane  and  gradually  extend 
over  the  whole  body.  As  a  rule,  argyria  does  not  produce 
serious  effects  on  the  health  of  the  subject.  The  pigmenta- 
tion is  due  to  a  deposit  of  silver  in  the  connective  tissues.  In 
the  skin  it  is  found  in  the  corium.  The  discolorization  is  per- 
manent. 

Name  a  vesicant  derived  from  (a)  the  animal  kingdom, 
<b)  the  vegetable  kingdom,   (c)   the  mineral  kingdom. 

(a)  Cantharides.  (b)  mustard,  (c)  iodine. 

Write  a  prescription  for  diarrhea  containing  an  alkali 
and  an  astringent  suitable  for  a  child  of  ten  years. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      :^95 

Jak.  1,  1910.  Waltkk. 

R     Sodii  bicarbonatis 3ii 

Bismutliis  subcarbonatis 5ii 

Tragacantha> 3  • 

Spts.  chlorofortni f  5  i 

Aquiie  cinnamomi f  §  iv 

M.  S. — Teaspoonfiil  every  four  hoiirsi. 

.I()Sf:PH  JoxEs,  M.  [X 

What  is  the  vulgar  name  for  veratrum  viride?  What  is 
its  active  principle  and  the  dose  of  the  principle? 

American  hellebore.  It  contains  several  active  principles, 
of  which  the  most  important  is  jervine.  The  dose  of  the 
tincture  is  1  Cc.  (15  minims). 

Name  three  drugs  which  are  administered  internally  to 
arrest  bleeding. 

Ergot,  gallic  acid  and  hematoxylon. 

What  are   the   therapeutic   uses  of   magnesia? 

It  is  used  as  an  antacid  and  laxative  in  acidity,  sick  head- 
ache, colic,  etc.,  and  as  an  antidote  in  poisoning  by  acids, 
arsenic,  phosphorus  and  tlie  mercuric  and  copper  salts. 

Mention  the  medicinal  uses  of  the  oil  of  turpentine. 

The  oil  of  turpentine  is  employed  externally  as  a  rube- 
facient and  countei'-irritant  in  many  conditions  causing  pain 
and  inflammation.  The  liniment  is  in  constant  iise  for  sprain, 
neuralgia  and  other  slight  local  affections.  Inter-nally  it  is 
best  employed  in  ulceration  and  hemorrhage  of  the  intestines, 
and  in  passive  hemorrhage  from  other  organs.  It  is  also  used 
a,s  an  anthelmintic  against  tape-worm,  and  is  of  value  in  flatu- 
lent colic.  It  is  employed  in  chronic  bronchitis  and  chronic 
inflammations  of  the  mucous  membranes  generally. 

For  what  are  the  preparations  of  juniper  used  in  medi- 
cines? 

Juniper    is   a   stomachic    tonic,    diaphoretic,    diuretic    and 
aphrodisiac.     The  oil  acts  therapeutically  like  the  oil  of  tur 
pentine,   and    may   bo   used    in    chronic    cystitis,   etc.,    but    is 
contra-indicated    wlioi-e    acute    inflannnations    of    the    kidney 
<?xist. 


396      THEBAPEUTICS  AND  MATERIA  ME  DIG  A. 

How  should  a  case  of  poisoning  with  atropine  be  treated? 

Tannic  acid  should  be  given  freely  and  the  stomach  emptied 
by  an  emetic  or  the  stomach-pump.  Collapse  must  be  met  by 
the  use  of  heart  stimulants,  such  as  ammonia,  alcohol  and  ni- 
troglycerin. Delirium  and  excitement  are  overcome  by  mor- 
phine or  chloral.    The  catheter  should  be  passed  frequently. 

What  is  the  vulgar  name  of  physostigma? 

Calabar  bean. 

What  are  the  therapeutic  uses  of  the  preparations  of 
zinc? 

The  acetate  is  used  as  an  astringent  application  in  conjunc-  ■ 
tivitis  and  subacute  gonorrhea.  The  precipitated  zinc  car- 
bonate is  used  as  a  sedative  astringent  in  acute  inflammatory 
affections  of  the  skin,  such  as  erythema  and  eczema.  The 
chloride  is  used  as  an  astringent  antiseptic  and  caustic.  It 
is  also  used  in  chronic  inflammation  of  the  mucous  mem- 
branes. The  oxide  is  employed  in  the  form  of  an  ointment 
or  powder  externally  as  a  mild  astringent  and  sedative  in 
burns,  acute  ulcers,  etc.  Internally  it  is  of  doubtful  value 
as  an  anti-spasmodic  and  anti-hydrotic.  The  phosphide  of 
zinc  is  employed  in  the  same  class  of  cases  in  which  phos- 
phorus is  indicated.  The  sulphate  of  zinc  is  employed  locally 
as  an  astringent,  and  internally  is  used  in  chronic  dysentery 
and  diarrhea,  as  well  as  an  emetic  in  large  doses  in  narcotic 
poisoning. 

Name  three  official  preparations  of  camphor. 

Aqua  camphorae,  linimentum  camphorae  and  spiritus  cam- 
phorge. 

Write  a  prescription  containing  some  preparation  of 
iron  in  a  delectable  form. 

Jan.  1,  1910.  For  Wm.  Jonks. 

R     Tinctune  feni  chloridi f  S'i 

Acidi  phosphorici  diluti f  3iii 

Spiritus  limonis f  3  i 

Syrupi • f  §  iiss 

Aqnam  ad f  §  vi 

M.  S  — Tablespoon  fill  after  meals. 

.loHN  SjVflTH,    M     D. 


THERAPEUTICS  AND  MATERIA  MEDICA.      397 

What  preparations  of  copper  are  used  in  medicine  and 
for  what  purposes? 

The  only  official  salt  of  copper  is  the  sulphate;  it  is  useful 
in  phosphorus  poisoning  both  as  an  emetic  and  a  chemical 
antidote.  The  application  of  the  solid  crystal  is  often  useful 
for  its  astringent  and  stimulating  qualities.  It  is  also  useful 
in  gonorrhea  in  the  subacute  stage.  Internally  it  is  some- 
times employed  in  chronic  diarrhea. 

What  are  the  therapeutic  uses  of  borax? 

Borax  is  sodium  borate,  which  is  a  powerful  antiseptic  and 
disinfectant.  It  has  been  used  internally  in  amenorrhea, 
dysmenorrhea  and  puerperal  convulsions  and  epilepsy.  In 
the  form  of  a  wash  it  is  of  value  as  an  anti-pruritic. 

With  what  remedies  should  spasmodic  croup  be  treated? 
Name  three  suitable  ones. 

With  emetics,  as  ipecac,  and  with  anti-spasmodics,  such  as 
the  bromides.    Lobelia  is  a  useful  remedy. 

Describe  the  medicinal  uses  of  hydrocyanic  acid. 

Hydrocyanic  acid  is  used  solely  to  allay  irritation  of  the 
peripheral  nerves.  Thus  it  is  employed  internally  for  the 
cough  of  phthisis  and  chronic  bronchitis,  for  gastralgia  in 
obstinate  vomiting,  and  externally  to  subdue  the  itching  in 
pruritis,  eczema  and  urticaria. 

Mention  the  conditions  which  affect  the  dosage  of  medi- 
cines. 

The  age  of  the  patient,  the  personal  idiosyncrasy,  the  con- 
dition of  the  heart,  kidneys,  nervous  and  respiratory  system. 

What  class  of  acids  would  you  use  to  acidify  alkaline 
urine? 

Benzoic  acid  and  its  derivatives,  as  benzoate  of  sodium  and 
ammonium. 

What  is  the  dose  of  phenacetine  as  an  antipyretic? 

Dose  0.500  Gm.  (71/2  grains)  every  4  to  6  hours. 


398      THERAPEUTICS  AND  MATERIA  MEDICA. 

What  is  the  composition  of  the  so=calIed  green  soap? 

Green  soap  is  prepared  from  potassa  and  linseed  oil. 

Where  does  arnica  grow  most  abundantly?  What  part 
of  the  plant  is  used  in  medicine? 

In  the  mountains  of  northern  Europe  and  Siberia.  Both 
the  flowers  and  the  roots  are  official. 

What  is  glycerin  and  what  are  its  therapeutic  uses? 

Glycerin  is  obtained  by  the  decomposition  of  vegetable  or 
animal  fats  or  fixed  oils.  It  is  a  triatomic  alcohol,  existing 
in  fats  and  fixed  oils  in  combination  with  the  fatty  acids. 
Externally  it  is  used  in  various  forms  as  an  emollient.  In 
the  various  acute  inflammations  of  the  fauces,  it  makes  an 
excellent  vehicle  for  carrying  other  drugs.  Being  hygro- 
scopic, it  not  only  depletes  the  turgid  vessels,  but  it  spreads 
the  medicant  over  the  entire  surface.  It  is  especially  useful 
in  tampons  in  such  conditions  as  uterine  congestion.  It  may 
be  employed  in  suppository  in  obstinate  constipation.  It  is 
sometimes  used  as  a  substitute  for  sugar  in  diabetes. 

How  many  grains  of  the  hydrochloride  of  cocaine  are 
contained  in  one  ounce  of  a  ten  per  cent,  solution? 

Forty-eight  grains. 

What  is  the  dose  of  the  fluid  extract  of  senna? 

Dose,  2  Cc.  (30  minims). 

What  injury  may  result  from  large  doses  or  long  con- 
tined  use  of  potassium  chlorate? 

The  chlorate  is  distinctly  irritant 'to  the  kidneys.  An  in- 
flammation of  these  organs  may  follow  its  use.  It  also 
causes  disintegration  of  red  blood  corpuscles. 

Give  the  habitat  of  squills  and  state  which  of  its  prep= 
arations  are  used  in  medicine. 

It  is  native  to  southern  Europe.  The  preparations  are 
vinegar  of  squills,  fluid  extract,  syrup,  compound  syrup  and 
tincture. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.      399 

Describe  the  therapeutic  uses  of  olive  oil  and  state 
where  it  is  principally  produced. 

It  is  produced  principally  in  southern  Europe,  California 
and  Australia.  Externally  used,  it  is  a  good  protective  from 
the  air,  and  if  rubbed  into  the  skin  is  absorbed  by  the  lym- 
phatics and  is  directly  nutritive.  Internally  it  is  a  food  and 
a  mild  laxative,  and  in  quantity  protects  the  mucous  mem- 
branes against  the  action  of  poisonous  substances. 

How  should  phosphorus  poisoning  be  treated? 

Immediate  full  dose  of  sulphate  of  copper,  which  is  an 
emetic  as  well  as  a  chemical  antidote.  Potassium  perman- 
ganate and  French  oil  of  turpentine  are  also  of  value.  Aro- 
matic spirits  of  ammonia  in  full  doses.  Strong  supportive 
measures  for  24  hours. 

What  is  the  dose  of  oleum  erigerontis? 

Dose  1  Cc.  (15  minims). 

Write  the  following  prescription  in  the  metric  system: 

R     Aminonii  bromidi 2  drams 

Sp.  ammonia'  aroraal 1  dram 

Aqua- 4  ounces 

Misce. 

R     Amrnonii  bromidi ^1 

Sp   ammonia'  aromat 4! 

Aqua- 120 

M  isce. 

What  is  the  dose  of  oleum  sabinae? 

Dose  0.05  Cc.  (1  minim). 

What  medicine  would  you  give  to  promote  bone  growth? 

One  of  the  preparations  of  lime,  as  lime  water,  or  the  car- 
bonate or  phosphate. 

What  is  the  alkaloid  of  pomegranate  and  for  what  is  it 
used? 

Pdlatierinp:  it  is  »  teniafuge. 


400      THERAPEUTICS  AND  MATERIA  MEDICA. 

By  what  other  name  is  saltpetre  known? 

Potassium  nitrate  and  nitre. 

In  what  dose  may  sulphonal  be  administered  to  an  adult 
to  produce  a  soporific  effect? 

It  may  be  given  in  average  dose  of  1  Gm.  (15  grains),  best 
in  hot  milk  aboiit  2  hours  before  retiring. 

To  what  chemical  change  does  sulphur  ointment  owe  its 
efficiency  as  a  parasiticide? 

Sulphur  ointment  contains  an  alkaline  ingredient  and  de- 
velops sulphides  which  are  powerful  anti-parasities. 

What  are  the  uses  of  lactic  acid  in  medical  practice  and 
what  pathologic  conditions  may  its  administration  pro= 
duce? 

It  is  employed  as  a  mild  caustic,  a  digestant  and  intestinal 
antiseptic.  It  is  a  valuable  local  remedy  in  laryngeal  tuber- 
culosis, and  internally  in  cholera,  typhoid  fever,  simple  diar- 
rhea and  the  diarrhea  of  infants.  It  is  supposed  to  cause 
acute  rheumatism  when  in  excess  and  free  in  the  blood. 

Write  the  following  prescription  in  the  metric  system: 

R     Morphins*"  sulphatis grains  6 

Sodii  boratis drams  4 

Aquie  camplionc fl.  ounces  6 


R     Morphinst-  sulpliatis 

Sodii  boratis 16 

Aquie  caraphorse 180 


What  is  the  effect  of  full  doses  of  opium  on  respiration 
and  to  what  extent  may  this  effect  be  safely  carried  in 
treatment? 

In  full  dose  there  is  irregular  and  slow  respiration.  It 
should  not  be  used  when  there  is  profuse  expectoration,  as 
the  lowering  of  excitability  of  the  respiratory  center  which  it 
produces  would  be  dangerous  in  such  a  case.  Morphine  is 
combined  with  atropine  to  overcome  the  effect  of  the  former 
on  the  circulation.  It  should  be  avoided  in  all  organic  dis- 
eases of  the  lungs  associated  with  weak  respiration. 


THERAPEUTICS  AND  MATERIA  MEDIC  A.     401 

Where  is  colocynth  obtained  and  for  what  is  it  used? 

Colocynth  is  the  fruit  of  citrullus  colocynthis  deprived 
of  its  rind.  The  plant  is  a  native  of  Spain  and  Asiatic 
Turkey.  It  is  classed  among  the  tonic,  astringent  and  resin- 
bearing  purgatives.  In  moderate  doses  it  increases  peristal- 
sis and  the  intestinal  glandular  secretion :  watery  evacuations 
with  griping  pain. 

What  is  the  comparative  action  of  strychnine  and  alco- 
hol on  the  arterioles? 

Strychnine  raises  the  arterial  pressure  by  stimulating  the 
vasomotor  center  in  the  medulla.  Alcohol  inhibits  the  vaso- 
motor system,  causing  dilatation  of  all  the  vessels  of  the  body, 
■especially  those  of  the  periphery.  The  blood  pressure  is 
raised,  however,  owing  to  the  great  increase  of  cardiac  action, 
which  overcomes  the  results  of  the  arteriole  dilatation. 

How  may  carbolic  acid  poisoning  be  produced  and  how 
treated? 

Carbolic  acid  poisoning  may  be  induced  by  the  local  use, 
■especially  of  weak  solutions,  of  the  acid,  as  well  as  by  the 
internal  ingestion  of  carbolic  acid  or  its  derivatives.  The 
treatment  of  the  poisoning  consists  of  the  administration  of 
the  antidote,  which  is  a  soluble  sulphate,  as  sulphate  of 
sodium ;  this  unites  with  the  acid,  forming  a  non-toxic  sulpho- 
carbolate.  Evacuation  of  the  stomach,  the  application  of 
external  heat  and  stimulants  and  the  use  of  mucilaginous 
drinks  are  indicated.  Whiskey  has  recently  been  found  to  be 
a  strong  antagonist  to  the  local  or  general  effects  of  carbolic 
acid  poisoning. 

Would  you  write  for  potassium  chlorate  and  tannin  in 
the  same  prescription?     Give  reason  for  your  answer. 

No.     There  woiild  be  danger  of  explosion. 

Mention  the  therapeutic  uses  of  gamboge. 

(iamboge  is  an  irritant  purgative,  decidedly  diaphoretic; 
its  catharsis  is  accompanied  by  vomiting  and  colic.     It  has 

2n 


402      THERAPEUTICS  AND  MATERIA  MEDICA. 

no  cholagogue  action.     Its  use,  for  the  most  part,  is  limited 
to  the  compound  cathartic  pill,  of  which  it  is  a  constituent. 

Where  is  kousso  obtained?  What  preparation  is  used 
and  for  what  purpose? 

Kousso  is  a  native  of  Abyssinia ;  it  is  used  in  the  form  of  the 
fluid  extract  as  an  anthelmintic  against  tape-worm. 

What  remedies  should  be  used  for  hemorrhages  front 
mucous  surfaces? 

The  astringents  and  vaso-eontractors ;  the  extract  of  supra- 
renal gland  is  probably  of  greatest  value;  ergot,  gallic  acid 
and  opium  are  employed  internally. 

On  what  theory  can  the  use  of  salol  in  diarrheal  diseases 
be  advocated? 

In  the  intestine  it  is  separated  into  carbolic  and  salicylic 
acids  and  acts  as  an  antiseptic.  It  is  free  from  irritating 
properties. 

For  what  is  copaiba  used  in  medicinal  practice? 

Copaiba  is  used  in  subacute  or  chronic  inflammations  of  the 
genito-urinary  tract. 

Name  a  drug  commonly  used  which  affects  the  color  of 
the  stools  without  altering  the  constituency,  and  explain 
the  cause. 

The  organic  salts  of  iron  blacken  the  feces  by  conversion 
into  the  sulphide. 

Describe  the  three  stages  of  chloroform  narcosis. 

1st  stage :  This  stage  is  very  short  and  the  symptoms  are 
very  similar  to  those  of  alcoholic  intoxication.  Consciousness 
is  not  lost  but  the  sensibility  is  generally  dulled.  Pupils  of 
eyes  dilated. 

2d  stage :  This  is  the  stage  of  anesthesia.  Consciousness  and 
sensibility  are  abolished,  the  muscles  are  relaxed  and  the  pa- 
tient is  quiet.  The  pulse  is  generally  normal  in  frequency, 
but  somewhat  weakened.     Pupils  of  eyes  contracted. 

3rd  stage :  This  stage  is  one  of  profound  narcosis  with  ster- 


THERAPEUTICS  AND  MATERIA  ME  DIG  A.      403 

torous  breathing,  intense  muscular  relaxation,  abolition  of  the 
ordinary  reflexes  and  fall  of  bodily  temperature.  Pulse  is 
weak  and  rapid.    Pupils  of  eyes  dilated. 

Describe  the  three  stages  of  anesthesia  under  ether. 

1st  stage:  Burning  in  the  fauces,  feeling  of  strangulation, 
sense  of  exhilaration,  lightness  in  the  head  with  a  buzzing  or 
roaring  in  the  ears.  These  symptoms  are  soon  followed  by  a 
semi-unconsciousness  with  visions  and  illusions.  Pupils  of 
eyes  dilated. 

2d  stage:  This  stage  begins  with  a  complete  loss  of  con- 
sciousness. Muscular  rigidity  soon  passes  off  and  the  patient 
is  quiet.  Respiration  is  slow  and  regular.  Pupils  of  eyes 
contracted.    Pulse  increased  in  rate  but  of  good  tension. 

3d  stage :  Same  as  the  third  stage  under  chloroform  narcosis. 

Give  the  contra-^indications  to  the  use  olf  anesthetics. 

Organic  brain  diseases,  including  tumors,  atheromatous  con- 
ditions of  the  blood  vessels,  organic  affections  of  the  heart, 
lungs  and  kidneys  (Wood).  Some  authorities  add  diabetes 
mellitus.  chronic  alcoholism  and  enlarged  tonsils. 

Why  is  the  use  of  ether  as  an  anesthetic  contra=indi- 
cated  in  diseases  of  the  lungs  and  kidneys? 

Because  it  is  eliminated  by  the  lungs  and  kidneys,  and  by 
its  irritating  quality  would  aggravate  the  diseased  condition. 

What  is  meant  by  cataphoric  application  of  a  remedy? 

By  cataphoric  application  of  a  remedy  is  meant  the  in- 
filtrating of  the  tissue  with  some  drug  by  electrical  osmosis. 

Give  the  indications  for  the  use   in   producing  sleep  of 

(a)  morphine,   (b)   chloral,   (c)   potassium   bromide. 

(a)   Morphine  is  used  when  sleeplessness  i.s  due  to  pain. 

(b)  Chloral  is  indicated  when  sleeplessness  is  due  to  mental 
overwork  and  where  a  more  powerful  hypnotic  than  potassium 
bromide  is  retpiired.  If  the  heart  or  stomach  are  in  bad  con- 
dition it  sliould  not  b(>  given,     (c)  Potassium  bromide  is  given 


404      THERAPEUTICS  AND  MATERIA  ME  DIG  A. 

when  insomnia  is  caused  by  cerebral  excitement,  nervous  ex- 
citement (especially  when  connected  with  the  genital  func- 
tion) and  motor  activity.  According  to  Wood  it  is  contra- 
indicated  by  an  excessive  irritability  of  the  gastro-intestinal 
nuieous  membrane  and  great  exhaustion. 

(a)  What  systemic  conditions  contra=indicate  the  use 
of  nitrous  oxide  gas?     (b)  State  why. 

(a)  Atheromatous  vessels,  fatty  heart  and  pulmonary  em- 
physema. (Burchard.)  (b)  Nitrous  oxide  gas  increases  blood 
pressure  and  in  atheromatous  degeneration  of  the  arteries 
this  may  result  in  rupture  of  these  vessels  and,  if  in  the  brain, 
apoplexy  may  ensue. 

In  fatty  heart  the  muscles  are  weakened,  and  on  account  of 
the  increased  resistance  in  the  blood-vessels  there  may  be 
sudden  dilatation  of  this  organ. 

In  pulmonary  emphysema  the  danger  is  in  the  engorgement 
of  the  blood  vessels  of  the  lungs  which  causes  an  increased  re- 
sistance to  the  right  heart,  which  may  result  in  the  Kudden 
dilatation  of  this  organ,  or  there  may  be  pulmonary  edema 
or  hemorrhage. 

(a)  What  are  topical  remedies?  (b)  Mention  two 
classes,     (c)  Give  two  examples  of  each. 

(a)  Topical  remedies  are  those  which  are  applied  locally, 
(b)  Plasters  and  liniments,  (c)  Belladonna  plaster  and  cap- 
sicum plaster — turpentine  liniment  and  chloroform  liniment. 

Give  the  signs  of  danger  in  chloroform  anesthesia  and 
tell  what  should  be  done. 

Lividity  of  the  face,  irregnilar  or  stertorous  breathing 
or  feebleness  of  the  pulse.  Withdraw  the  anesthetic,  lower 
the  head,  use  artificial  respiration  and  give  a  hypodermic 
injection  of  strychnine,  digitalis,  or  atropine. 

When  is  chlorofrm  preferred  to  ether  as  an  anesthetic? 

In  acute  inflammation  of  the  bronchi  or  lungs,  aneurism, 
atheroma  and  nephritis. 


THERAPEUTICIS  AND  MATERIA  MEDICA.      405 

Name  the  accidents  that  may  happen  during  the  admin- 
istration of  ether,  and  give  the  treatment  in  each  case. 

In  the  early  part  of  the  administration  of  ether  we  may 
have  failure  of  respiration,  which  is  due  to  reflex  spasm  of 
the  laryngeal  muscles  excited  by  the  ether.  By  giving  more 
air  with  the  ether  we  can  correct  this  trouble. 

Embarrassed  respiration  may  be  due  to  the  accumulation 
of  mucus  in  the  upper  air  passages.  In  this  condition  we  sim- 
ply turn  the  head  to  one  side. 

Respiratory  failure  may  be  caused  by  the  action  of  the 
ether  on  the  respiratory  centre.  In  tfils  case  we  withdraw 
the  ether;  push  the  jaw  forward  by  pressing  on  its  angles, 
draw  the  tongue  forward  by  means  of  a  tenaculum  or  for- 
ceps and  make  rhythmic  traction  of  the  tongue.  Pour  ether 
on  the  abdomen  or  chest  in  order  to  stimulate  inspiration  by 
reflex  action,  give  strychnine  and  atropine  hypodermically. 
Practice  artificial  respiration.     Administer  oxygen. 

Name  the  most  common  after=effects  of  the  administra- 
tion of  ether. 

Nausea  and  vomiting. 

Under  what  conditions  is  ether  contra=indicated  as  an 
anesthetic? 

In  acute  inflammatory  infections  of  the  respiratory  tract, 
advanced  arteriosclerosis,  severe  nephritis,  especially  when 
associated  with  cardiovascular  lesions  and  anemia  when  the 
hemoglobin  is  less  than  30%.  Diabetes  raellitus,  especially 
when  well  established  and  associated  with  acetonuria 
(Stevens) . 

Convert  the  following  popular  measures  into  their  ap- 
proximate metric  equivalents:  i  drop,  i  teaspoon,  i  des- 
sertspoon, I  tablespoon,  i  wineglass. 

1  drop,  O.OG  Cc. ;  1  teaspoon,  4  Cc. ;  1  dessertspoon,  7.5  Cc; 
1  tablespoon,  15.0  Cc. ;  1  wineglass,  30  Cc. 

Give  the  adult  maximum  dose  of  the  following:  atropine. 


406      THEBAPEVTICS  AND  MATERIA  ME  DIG  A. 

arsenic  compounds,  strychnine,  apomorphine  compounds, 
mercury  salts,  silver  salts,  acetanilid,  sulphonal. 

Atropine,  gr.  Vgo ;  arsenic  compound,  salts,  gr.  ^/^^ ;  strych- 
nine, gr.  Vg^;  apomorphine,  gr.  %;  mercury  salts,  gr.  Vjo; 
silver  salts,  gr.  i/^ ;  acetanilid,  gr.  v ;  sulphonal,  gr.  xv. 

Give  symptoms  of  poisoning  from  chloral  hydrate. 

Mental  hebetude  or  stupor,  subnormal  temperature,  nausea, 
vomiting,  purging;  erythematous  or  papular,  and  sometimes 
vesicular  or  petechial  eruption.  Feeble,  running  pulse,  shal- 
low respirations. 


DIAGNOSIS  AND  PRACTICE. 


Diagnosticate  iritis  and  keratitis. 

Iritis.  Inflammation  of  iris.  Caused  by  gout,  rheumatism 
or  syphilis.  More  common  in  adults.  May  affect  both  eyes 
simultaneously.  Pain  intense  and  throbbing.  Pupil  con- 
tracted.   Salicylates  relieve. 

Keratitis.  Inflammation  of  cornea.  Commonly  due  to  con- 
genital syphilis.  More  common  before  or  at  puberty.  Af- 
fects one  eye  at  first,  the  other  one  at  a  later  period.  Cornea 
hazy,  with  hyperemia  of  ciliary  region.  New  blood-vessels 
form  in  center  of  opacity.  No  tendency  to  ulcerate.  Course 
prolonged.    Pain  not  severe.     Iodides  relieve. 

Differentiate  cerebro=spinaI  meningitis  and  tubercular 
meningitis. 

Cerebro-spinal  meningitis.  Onset  abrupt  with  headache, 
chill,  fever  and  vomiting.  Occure  at  any  age.  Spotted,  pur- 
puric or  petechial,  rashes  appear,  also  herpes  facialis.  Opis- 
thotonos marked.  Headache  severe.  Leucocytosis.  Choroidal 
tubercles  absent.     Lumbar  puncture  shows  pus  cells. 

Tubercular  meningitis.  Onset  gradual.  Usually  between 
two  and  seven  years  of  age.  Tubercular  process  elsewhere  in 
body.  Xo  characteristic  rash.  Hereditary.  Tubercle  bacil- 
lus. Retracted  abdomen.  Headache  not  so  severe.  Cheyne- 
St^kes  breathing  more  common.  Leueopenia.  Choroidal 
tubercles  present.  Lumbar  puncture,  serum  with  lympho- 
cytes. 

Name  the  characteristic  features  present  in  the  blood  in 
(a)  Chlorosis,   (b)    [Progressive  pernicious  anemia. 

(a)  Moderate  reduction  in  reds,  which  are  smaller  and  pale. 

(  407  ) 


408  DIAGNOSIS  AND  PB  ACT  ICE. 

Hemoglobin    greatly    reduced,    even    to    15%.      Leucocytosis- 
moderate  or  none. 

(b)  Marked  decrease  in  reds  to  a  million  or  less.  Hemo- 
globin decreased,  but  each  red  cell  is  richer  in  this  element, 
increasing  its  size.  Poikilocytosis,  abundant  nucleated  reds 
common.     Leukopenia. 

What  are  the  symptoms  and  signs  present  in  acute 
articular  rheumatism  with  endocarditis? 

The  usual  symptoms  of  sharp  pain  and  tenderness  in  joints, 
changing  location  frequently,  acid  secretions,  profuse  sweats, 
irregular  temperature,  leucocytosis.  Symptoms  of  endocar- 
ditis, precordial  discomfort,  dyspnea,  palpitation,  vertigo  on 
exertion,  sometimes  embolic  symptoms  in  brain.  Ausculation 
reveals  a  low  and  soft  blowing  systolic  murmur  in  mitral 
area,  with  accented  second  pulmonic  sound. 

What  are  the  symptoms  and  characteristic  findings  in 
diabetic  coma? 

Rapid  onset  with  delirium  or  restlessness,  progressing  to 
profound  coma.  Emaciation,  fruity  odor  of  breath  and 
urine.  Kussmaul's  air  hunger  with  deep  breathing.  No 
oedema  of  the  lungs  till  at  the  close.  Pulse  low  tension  and 
rapid,  temperature  much  lowered,  urine  decreased,  and  shows 
beta-oxybutyric  acid. 

Differentiate  pulmonary  and  gastric  hemorrhage. 

Pulmonary  hemorrhage  is  usually  preceded  by  a  saline 
taste  in  the  mouth,  and  accompanied  by  a  short  jerky  cough. 
The  blood  is  bright  red  and  frothy,  later  mixed  with  mucus. 

Gastric  bleeding  is  usually  preceded  by  a  feeling  of  nausea 
and  epigastric  distress,  and  accompanied  by  vomiting.  If 
arterial  in  character,  it  may  come  up  unchanged  and  bright 
red;  if  venous,  it  then  appears  as  "  coffee  ground  "  or  "  cur- 
rent jelly  "  clots,  and  is  usually  mixed  with  food  particles. 
The  blood  test  with  the  feces  is  positive  in  the  latter  con- 
dition. 


^  DIAGNOSIS  AND  PRACTICE.  40{> 

Make  a  differential  diagnosis  of  pleuritis  and  pleuro= 
dynia. 

Pleuritis  symptoms  are  fever,  sharp  pain  upon  coughing  or 
de€p  breathing,  and  some  prostration.  A  friction  sound  is 
audible.  Pleurodynia  is  frequently  a  part  of  a  general  mus- 
cular rheumatism,  and  presents  no  physical  signs. 

What  is  the  importance  of  body  temperature  in  making 
a  diagnosis?  State  the  average  normal  temperature  as 
taken  by  (a)  the  mouth,  (b)  the  axilla,  (c)  the  rectum, 
(d)  the  vagina. 

Certain  fevers  show  a  definite  range  of  temperature,  which 
helps  to  make  the  picture  of  the  disease,  and  also  to  determine 
the  stage  or  virulence  of  the  process,  as  at  the  fastigium  of 
typhoid  fever,  (a)  98.6°  F.  (b)  98.6°  F.  (c)  100.4°  F. 
(d)  100.9°  F. 

Give  the  temperature  curve  in  incipient  tuberculosis. 
What  changes  characteristic  of  tuberculosis  may  occur  in 
the  hand  of  a  tuberculous  patient? 

The  morning  temperature  is  subnormal,  the  afternoon 
always  showing  an  elevation  to  99°  or  100°.  Clubbing  of 
the  finger  tips  often  occurs,  particularly  in  young  persons, 
due  to  venous  and  lymphatic  stasis.  The  finger  nails  may 
show  combined  anemia  and  cyanosis. 

What  changes  take  place  in  the  heart  in  mitral  re= 
gurgitation? 

The  left  auricle  is  dilated  by  the  reflux  of  blood  from  the 
left  ventricle ;  this  in  turn  is  dilated  by  the  increased  amount 
of  blood  returned  from  the  auricle ;  both  chambers  now  hyper- 
trophy to  maintain  compensation;  after  the  auricle  undergoes 
secondary  dilatation,  the  blood  in  the  lungs  is  congested,  and 
now  puts  a  great  load  on  the  right  ventricle,  which  also  takes 
on  great  hypertrophy  to  maintain  full  compensation. 

What    is   the    clinical    significance    of    (a)    an    excess   of 


410  DIAGNOSIS  AND  PRACTICE. 

sodium  chloride  in  the  urine,      (b)  a  diminution  of  sodium 
chloride  in  the  urine? 

(a)  Increase  in  salt  ingested;  in  diabetes  insipidus,  and 
during  absorption  of  exudates  and  transudates.  Diuretics 
and  salicylates  will  also  increase  it. 

(b)  In  certain  fevers,  as  typhoid,  lobar  pneumonia,  acute 
rheumatic  fever,  diarrhea,  and  where  there  are  accumulations 
of  exudates  or  transudates. 

State  the  value  of  the  ordinary  leucocyte  count  in  dif= 
ferential  diagnosis. 

It  serves  to  indicate  pus  complications  in  certain  condi- 
tions, as  appendicitis;  to  confirm  the  diagnosis  of  malaria, 
syphilis,  early  tuberculosis,  etc.,  and  to  measure  the  resist- 
ance of  the  patient,  as  in  lobar  pneumonia. 

State  the  course  of  the  temperature  in  (a)  incipient 
tuberculosis,  (b)  typhoid  fever,  (c)  tonsillitis. 

(a)  Persistent  subnormal  morning,  and  slight  evening  ele- 
vation, until  mixed  infection  occurs. 

(b)  Gradual  step-like  ascent  for  five  days,  then  high  and 
continuous,  of  the  remittent  type  until  defervescence  occurs, 
temperature  then  reaching  normal  by  lysis  in  7  to  10  days. 

(c)  Highest  point  103°-105°,  reached  during  the  first  day, 
with  rapid  decline  to  normal  in  from  3  to  5  days. 

Define  each  of  the  following  terms:  (a)  orthopnea, 
(b)  opisthotonos,  (c)  astasia,  (d)  paraplegia,  (e)  uremia. 
Mention  a  disease  in  which  each  of  these  symptoms  is 
present. 

(a)  The  upright  position  to  relieve  difficult  respiration. 
Asthma. 

(b)  Arching  backward  of  the  body,  with  only  heels  and 
occiput  touching  the  bed.  owing  to  tetanic  contractions  of 
the  back  muscles.     Tetanus. 

(c)  Inability  to  stand  properly  in  an  upright  position. 
Hysteria. 

(d)  Paralysis  of  the  lower  extremities.    Myelitis. 


DIAGNOSIS  AND  PRACTICE.  411 

(e)  A  condition  resulting  from  retained  toxie  siit)sfanees 
which  should  be  normally  excreted  by  the  kidneys.  Acuie 
nephritis. 

Give  the  temperature  chart  in  each  of  the  following 
diseases:  (a)  typhoid  fever,  terminating  in  recovery,  (b) 
croupous  pneumonitis  terminating  in  recovery,  (c)  inter= 
mittent  fever  (quotidian),  (d)  variola  terminating  in 
death  on  the  12th  day. 

(a)  Step-like  ascent,  rising  one  degree  daily,  until  the 
fastigium  or  5th  day,  then  continuous  and  remittent  for  ten 
days,  ranging  from  101°  to  104°,  and  declining  by  lysis, 
reaching  normal  by  the  21st  day. 

(b)  Sudden  rise  to  104°,  high  and  continuous  without  re- 
mission until  the  crisis  on  5th  to  the  9th  day,  when  it  comes 
down  to  normal  in  a  few  hours. 

(c)  A  daily  cycle;  subnormal  during  chill,  rising  to  104°- 
105°,  and  remaining  so  for  a  few  hours,  then  rapidly  declin- 
ing to  normal  during  the  sweating  stage. 

(d)  Subnormal  during  chill,  quickly  rising  to  104°-105°, 
and  continuously  high  until  rash  appears  on  fourth  day, 
drops  to  nearly  normal  for  three  days  (vesicular  stage),  then 
rises  and  becomes  hectic  during  the  suppurative  stage,  when 
complications  are  frequent,  and  death  occurs. 

Give  the  clinical  history  of  a  case  of  duodenitis. 

History  of  previous  dyspepsia,  which  may  persist.  Un- 
easiness two  hours  after  eating  with  local  pain  and  tenderness. 
Constipation  is  the  rule,  and  jaundice  is  the  strongest  point 
to  confirm  the  diagnosis.  It  may  persist  for  a  long  period, 
and  be  the  cause  of  gallstone  formation  or  pancreatic  involve- 
ment. 

Give  the  situation  of  each  of  the  following  valves:  (a) 
Mitral,  (b)  tricuspid,  (c)  pulmonary,  (d)  aortic.  Where 
are  the  tones  of  each  best  heard? 

(a)  Behind  the  left  half  of  the  sternum  at  the  third  and 
fourth  interspace,     (b)  Behind  the  middle  of  the  lower  fourth 


412  DIAGNOSIS  AND  PRACTICE. 

of  the  sternum,  corresponding  to  the  fourth  and  fifth  costal 
cartilages,  (c)  At  the  third  left  chondro-costal  margin,  (d) 
Behind  the  left  half  of  the  sternum,  on  a  level  with  the  third 
interspace. 

(a)  At  the  apex,  (b)  Lower  sternum  at  fifth  left  rib. 
(c)  Second  left  interspace  at  costo-sternal  junction,  (d)  Sec- 
ond right  interspace  at  costo-sternal  junction. 

State  the  clinical  features  of  so=caIied  exophthalmic 
goitre. 

Most  common  in  women  between  20  and  30.  Some  heredi- 
tary tendency.  Due  to  excessive  thyroid  function.  Rapid 
onset  with  enlargement  of  thyroid  gland,  tachycardia,  ex- 
ophthalmos and  tremors  as  cardinal  symptoms.  Pigmentation, 
itching  or  edema  of  the  skin  may  occur.  Nervous  diarrhea 
is  common.  Anemia,  emaciation,  slight  fever,  and  mental 
changes  occur.  The  course  may  be  acute.  A  few  recover,  but 
most  cases  show  persistence  of  some  symptoms  throughout  life. 

What  are  the  clinical  indications  in  syphilitic  tumor  of 
the  brain? 

Intense  headaches,'  cranial  nerve  palsies,  optic  neuritis, 
somnolence,  coma  or  hemiplegia,  nausea,  vomiting,  vertigo, 
mental  irritability  and  dullness,  epileptoid  convulsions  and 
polyuria.  The  condition  is  usually  that  of  meningitis,  asso- 
ciated with  gumma. 

Differentiate  erysipelas  and  erythema. 

Erysipelas  is  a  specific  infection  with  chills,  fever,  sweats, 
leucocytosis,  usually  local  in  its  rash,  which  spreads  to  con- 
tiguous surfaces,  and  has  a  distinct  line  of  demarcation.  It 
lasts  for  two  weeks  or  longer. 

Erythema  results  from  dietetic  errors,  certain  drugs,  or 
skin  irritation,  is  sudden  in  onset.  May  cover  all  parts  of  the 
body  simultaneously.  Reaches  its  height  promptly,  and  fadea 
in  a  day  or  two.  It  causes  no  profound  systematic  symptoma 
except  itching  and  restlessness. 


DIAGNOSIS  AND  PRACTICE.  413 

Differentiate  chronic  catarrhal  laryngitis  and  laryngeal 
tuberculosis. 

History  of  alcohol,  tobacco  or  public  speaking,  with  general 
health  not  affected. 

Voice  hoarse  and  harsh.  Cough,  with  thick  secretion,  chiefly 
of  mucus.  Evidence  of  tuberculosis  in  lungs.  Hoarsi^ness 
or  aphonia,  dysphagia,  cough,  hemoptysis,  sputum  muco-puru- 
lent,  and  contains  tubercle  bacilli.  Larynx  is  red,  swollen  and 
granular,  or  shows  infiltration  and  superficial  ulceration, 
usually  multiple,  with  tendency  to  coalesce. 

How  may  the  source  of  blood  discharge  in  hematuria  be 
determined? 

Blood  of  renal  origin  is  constantly  and  evenly  mixed  with 
the  urine,  which  is  acid,  of  dark,  even  wine  color,  and  contains 
casts  and  renal  cells.  Red  cells  numerous  and  pale.  Lumbar 
pain,  but  micturition  normal.  Bladder  bleeding  is  in  larger 
amount,  merely  mixed  A\4th  urine,  showing  more  at  the  end 
of  urination,  reaction  alkaline,  clots  easily  and  shows  bladder 
<3ells  and  mucus.    Strangury  common. 

How  is  the  eye  affected  by  paralysis  of  the  third  nerve? 

Ptosis,  I0.SS  of  accommodation,  diplopia,  and  external  or  di- 
vergent squint. 

What  are  the  symptoms  of  (a)  the  tertian,  and  (b)  the 
quartan  form  of  malaria? 

(a)  Paroxysms  consist  of  a  chill,  lasting  two  hours,  fol- 
lowed by  the  hot  stage,  lasting  four  or  five  hours,  the  tem- 
perature reaching  105°  F.,  the  pulse  full  and  bounding,  with 
rending  headache  and  thirst.  This  is  followed  by  sweating, 
which  promptly  relieves  the  symptoms.  The  skin  is  sallow, 
-and  there  may  be  diarrhea.  Characteristic  blood  changes 
are  found.     The  cycle  is  repeated  every  forty-eight  hours. 

(b)  Symptoms  differ  in  no  way  from  the  tertian  form,  ex- 
■ccpt  that  the  cycle  recurs  every  seventy-two  hours. 


414  DIAGNOSIS  AND  PRACTICE. 

Differentiate  lung  hepatization  and  pleuritis  with  ef= 
fusion. 

(a)  On  inspection,  the  apex  beat  is  normal,  and  strongly 
acting.  Herpes  facialis  and  mahogany  blush.  Tactile  frem- 
itus is  increased,  and  the  pulse  is  full  and  bounding  but 
compressible.  Dulness  is  fixed,  and  sharply  demarcated  from 
the  lung  resonance.  Auscultation  shows  strong  tubular 
breathing  with  broncophony  and  pectoriloquy.  Sputum  char- 
acteristic. 

(b)  Apex  displaced  and  weak;  pallor  of  face.  Tactile 
fremitus  absent,  and  pulse  low  in  tension.  Dulness  is  mov- 
able on  change  of  posture.  Breathing  is  tubular  but  very 
distant. 

Differentiate  melancholia  and  dementia. 

Melancholia  is  characterized  by  slowly  developing  emotional 
expression,  apprehension  or  anxiety,  with  vague,  peculiar 
symptoms  of  headache,  pressure,  vertigo,  insomnia,  irrita- 
bility, etc.     Orientation  is  usually  good. 

Dementia  shows  early  delusions  of  grandeur  or  abasement, 
lack  of  orientation,  failure  of  memory  for  recent  events  and 
for  voluntary  attention.  The  progress  downward  is  rapid, 
and  goes  on  to  uncleanliness  of  person,  stupor  and  death. 

Differentiate  iritis  and  acute  glaucoma. 

Iritis.  Any  age.  Syphilis,  gout,  rheumatism,  trauma,  or 
tuberculosis.  Pupil  contracted.  Impaired  mobility  or  ir- 
regular pupil.  Rosy  zone  surrounds  the  cornea.  Cornea 
hazy.  Pain  intense  and  worse  at  night.  Tension  normal. 
Quick  response  to  iodides.  Aqueous  humor  turbid.  Lach- 
rymation. 

Acute  glaucoma.  Commonly  in  late  adult  life.  Pupil  di- 
lated. Halo  around  lights.  Outer  ring  red,  inner  one  bluish- 
green.  Cornea  steamy  and  anesthetic.  Pain  intense  at  on- 
set. Tension  much  increased.  No  response  to  medicinal  treat- 
ment.    Optic  disc  is  hollowed. 

Describe  the  condition  known  as  catalepsy. 

Rigidity  affecting  the   voluntary  muscles,   whereby  an  ex- 


DIAGNOSIS  AND  PRACTICE.  415 

tremity  may  be  maintained  in  opposition  to  gravity  for  a 
long  period.  Common  in  hysteria,  paresis,  and  may  occur  in 
brain  tumors  and  meningitis. 

State  the  distinctive  characteristics  of  mastoiditis  re= 
quiring  an  operation. 

General  symptoms  of  sepsis,  as  chills,  fevers,  sweats,  leu- 
cocytosis.  Local  symptoms  of  edema  or  tumefaction  of  the 
mastoid  process  or  the  glands  of  this  area.  Headache,  nausea, 
vomiting  and  dulled  mentality. 

How  does  eczema  differ  from  herpes  zoster? 

Eczema  is  usually  bilateral.  The  lesions  are  of  various 
forms,  do  not  follow  nerve  trunks,  and  the  vesicles  are  fine. 
Intense  itching  but  no  neuralgia. 

Herpes  zoster  is  a  unilateral  eruption,  consisting  of  groups 
of  large  vesicles  upon  an  erythematous  base,  follows  the 
course  of  cutaneous  nerves,  and  always  accompanied  by  neur- 
itis. 

Describe  a  typical  case  of  laryngismus  stridulus. 

A  child  of  between  six  months  and  two  years  is  taken  sud- 
denly during  sleep  with  spasm  of  the  adductors  of  the  larynx. 
The  breathing  ceases,  the  face  is  cyanotic,  the  child  is  rest- 
less and  terror-stricken,  but  in  a  few  seconds  the  seizure  ter- 
minates with  a  high-pitched,  crowing  inspiration.  These 
attacks  are  liable  to  frequent  recurrence.  General  symptoms 
are  absent. 

Relate  the  symptoms  of  acute  pancreatitis. 

Occurs  in  middle-aged  males  of  alcoholic  habit,  or  from 
gastro-duodenal  catarrh  or  injury.  Sudden  onset,  with  severe 
paroxysmal,  deep-seated  pain,  constipation,  and  distension 
of  upper  abdomen.  A  chill  followed  l)y  moderate  fever  is  seen 
early.  Tenderness  and  resistance  between  the  ensiform  and 
umbilicus;  later,  tender  spots  on  the  abdominal  wall.  Delir- 
ium, dyspnea,  cyanosis,  hiccup,  fatty  diarrhea,  and  albumin- 
uria may  be  present.  Death  usually  occurs  between  the  sec- 
ond and  fourth  day  of  the  disease. 


416  DIAGNOSIS  AND  PRACTICE. 

Describe  Cheyne=Stokes  respiration,  and  state  its  signi= 
ficance. 

A  form  of  irregular  rhythm  in  breathing,  the  patient  first 
ceasing  to  breathe  (apnea),  then  a  slight,  slow  respiration, 
followed  by  others  of  increasing  depth  and  rapidity,  until 
actual  dyspnea  occurs,  then  a  gradual  decline  to  the  period 
of  apnea.  The  cycle  varies  from  30  seconds  to  2  minutes. 
It  suggests  profound  irritation  of  the  respiratory  centers  in 
■disease,  as  in  apoplexy,  uremia,  brain  tumors,  meningitis,  ad- 
vanced myocarditis,  diabetes,  the  typhoid  state,  etc.  It  oc- 
curs physiologically  in  infants. 

State  the  relation  that  the  pulse  and  respiration  bear 
to  the  temperature. 

The  pulse  increases  8  to  10  beats  per  minute,  and  the  rec- 
piration  4  to  5  times  per  minute  for  every  degree  of  rise  in 
temperature. 

State  the  conditions  of  the  tongue  that  are  of  diagnostic 
value. 

Its  color,  size,  coating,  dryness,  lesions,  and  mobility.  Red 
in  scarlatina,  yellow  early  in  jaundice,  large  in  acromegaly, 
swollen  in  edema,  atrophied  in  palsies,  coated  in  typhoid 
fever,  very  dry  in  diabetes  and  adynamic  conditions,  nodular 
as  in  gumma  or  epithelioma. 

What  are  the  diagnostic  features  of  acute  gastritis  due 
to  arsenic  poisoning? 

Nausea,  vomiting,  internal  burning  along  the  gullet  and  in 
■epigastrium,  cramps  in  calves  of  legs.  Vomitus  contains 
much  mucus  and  streaks  of  blood.  Arsenic  may  be  recovered 
from  the  vomitus. 

Give  the  details  of  a  digital  examination  of  the  rectum. 

Bowels  should  be  thoroughly  emptied.  Local  or  general 
anesthesia  if  necessary.  Patient  on  back  or  side,  with  ab- 
dominal walls  relaxed.  Index  finger  introduced  and  swept 
around  will  discover  capacity  of  sigmoid,  presence  of  piles, 
polypi,  foreign  bodies,  strictures,  and  muscle  thickness. 


DIAGNOSIS  AND  PRACTICE.  417 

What  are  the  symptoms  of  aneurism  of  the  abdominal 
aorta? 

Dull,  boring,  or  neuralgic  pain,  numbness  of  extremities 
or  paraplegia,  occasionally  jaundice,  gastralgia,  nausea  and 
vomiting.  Presence  of  expansile  pulsating  tumor  with  de- 
layed or  absent  femoral  pulse.     Accented  second  aortic  sound. 

HoM  maj  blood  pressure  be  determined?  Of  what  dia= 
gnostic  value  is  the  knowledge  of  a  patient's  blood  pres= 
sure? 

(aj  By  the  use  of  the  sphygmomanometer,  which  deter- 
mines the  power  of  the  left  ventricle  and  the  condition  of  the 
arteries  and  the  flow  of  blood. 

(b)  It  gives  exact  information  to  indicate  the  need  or  re- 
sults of  treatment,  as  for  cardiac  stimulation  or  sedation ;  or 
in  arterial  hypertension  or  hypotension. 

Give  the  value  and  technic  of  pleural  exploratory 
puncture. 

Value :  To  confirm  the  signs  of  fluid,  the  character  of  the 
same  and  to  relieve  pressure  by  fluid  or  air. 

Technic :  Skin  carefully  cleansed.  Light  local  anesthesia. 
Hypodermic  syringe  with  long  needle,  closed.  Patient  in 
semi-recumbent  posture.  Make  a  quick  thrust  in  the  inter- 
space selected,  avoiding  the  rib  and  intercostal  artery.  When 
needle  enters  the  cavity  draw  out  plunger  slowly,  and  permit 
to  fill.  If  no  fluid  comes,  turn  the  needle  gently  to  one  side. 
Pull  needle  out  quickly.  Seal  the  point  of  insertion  with  cotton 
and  collodion,  and  keep  the  patient  at  rest  for  a  short  time 
afterward. 

What  are  the  pathognomonic  symptoms  of  incipient  tu- 
berculosis? 

Languor,  weakness,  pallor,  loss  in  weight,  dyspnea,  chilli- 
ness, loss  of  appetite,  dyspepsia,  slight  fever,  night  sweats, 
cough.  o.xpf'C'tnration.  in  some  ca.ses  hemoptysis. 

Differentiate  cancer  of  the  stomach  and  duodenal  ulcer. 

(a)   Occurs  usually  over  forty,  either  sex.     Alcoholism  or 
27 


418  DIAGNOSIS  AND  PRACTICE. 

previous  ulcer,  progressive  emaciation  and  cachexia,  pain 
constant,  dull  and  boring,  coffee-ground  vomit,  absence  of 
HCl,  and  presence  of  Oppler-Boas  bacillus.  Occult  blood  test 
frequently  present. 

(b)  Earlier  age,  males.  Pain  in  right  hypochondrium  2 
or  3  hours  after  meals.  Anemia.  Melena  after  gastralgic  at- 
tacks. Sometimes  jaundice.  Occult  blood  test  constant. 
Stomach  shows  hyperacidity. 

Differentiate  tonsillitis  and  diphtheria. 

Onset  abrupt  with  high  fever  at  onset.  Pain  intense  and 
sharp,  general  myalgia.  Face  flushed.  Pulse  high  and  wiry. 
Membrane  first  punctate,  then  confluent,  but  always  confined 
to  tonsils.  May  come  off  easily  without  bleeding,  and  does 
not  tend  to  recur.    No  albuminuria.    No  sequels  as  a  rule. 

Onset  less  abrupt.  Marked  pallor  and  weakness.  Fever 
progressive.  Pain  less  intense,  dysphagia  from  muscle  palsy, 
lymph  glands  swollen.  Membrane  spreads  beyond  tonsil  and 
involves  uvula,  arches,  or  pharynx.  Albuminuria.  Klebs- 
Leffler  bacilli  positive.    Palsies  common  as  a  sequel. 

Differentiate  lupus  vulgaris  and  epithelioma  of  the 
face. 

Lupus  vulgaris  develops  early  in  life  in  strumous  persons. 
Often  tubercular  foci  elsewhere.  Nodules  are  soft.  Ulcers 
superficial,  with  undermined  edges. 

Epithelioma  begins  late  in  life.  Usually  grafted  on  moles 
or  warts,  the  center  having  an  ulcer,  the  border  being  hard, 
elevated,  and  very  vascular. 

Differentiate  chronic  glaucoma  and  optic  atrophy. 

Chronic  glaucoma.  Halo  of  red  and  green  about  lights. 
Decreased  accommodation  in  vision.  Dilated  pupil.  Anes- 
thesia of  cornea.  Cornea  cloudy.  Cupping  of  optic  disc. 
Arterial  pulsation  in  the  papilla. 

Optic  atrophy.  History  of  syphilis,  brain  tumor,  lead  or 
other  poison,  etc.  Vision  gradually  weakens.  Pupils  normal. 
Eye  ground  shows  diminished  size  of  arteries,  dilated  veins,, 
and  swelling  of  the  optic  disc.     Hemorrhages  frequent. 


DIAGNOSIS  AND  PRACTICE.  419 

State  the  character  of  the  cough  and  expectoration  in 
(a)  catarrhal  pneumonia,  (b)  croupous  pneumonia. 

(a)  Paroxysmal  and  prolonged.  Abundant  yellow  sputum, 
composed  of  mucus,  pus  cells,  and  pus  organisms. 

(b)  Short,  hacking  and  frequent.  In  the  second  stage  the 
sputum  is  scanty,  brown  and  rusty,  thick,  viscid  and  tena- 
cious, and  composed  chiefly  of  fibrin  and  the  germ.  In  the 
third  stage  it  is  freer,  and  composed  chiefly  of  pus  cells. 

Describe  the  eruption  of  (a)  measles,  (b)  small  pox,  (c) 
typhoid  fever. 

(a;  Maculo-papular.  crescentic  in  outline,  appears  on  the 
4th  day,  first  on  the  neck,  face  and  thorax,  spreading  over 
the  body. 

(b)  First  appears  on  forehead  and  wrists  on  the  fourth 
day,  extending  gradually  over  entire  body  surface,  going 
through  the  stages  of  papule,  vesicle,  pustule,  and  scab,  each 
stage  lasting  3  days;  the  beginning  papule  feels  "  shotty  '* 
under  the  skin ;  the  vesicle  is  multilocular ;  the  pustule  be- 
comes full  and  rounded,  and  becomes  confluent;  the  scab 
forms  from  rupture  or  absorption  of  the  pus.  Pitting  follows, 
and  is  permanent  if  the  true  skin  has  been  involved. 

(c)  Discrete,  lenticular  papule  appears  on  the  8th  or  10th 
day,  in  crops  of  about  a  dozen.  Disappears  on  pressure,  and 
reappeare  when  pressure  removed.  Two  or  three  crops  is 
usual,  each  crop  lasting  three  or  more  days. 

Differentiate  psoriasis  and  eczema  squamosum. 

Psoriasis.  Afl:'ects  extensor  surfaces.  Rounded  circum- 
scribed lesions  covered  with  silvery  scales.  Tendency  to  re- 
currence.    Itching  mild.     Occurs  in  early  life. 

Eczema  squamosum.  Afi'ects  flexor  surfaces.  Irregular 
areas,  larger  in  size,  with  tendency  to  spread.  Yellowish 
scales,  with  crust  formation.  More  or  less  permanent  erup- 
tion, with  change  in  form  of  lesions.  Itching  severe.  Occurs 
in  middle  age. 


420  DIAGNOSIS  AND  PRACTICE. 

Differentiate  (a)  Labial  chancre,  (b)  Epithelioma,  (c) 
Chancroid,  (d)  Herpes. 

(a)  History  of  contagion,  single,  elevated,  indurated  base, 
not  painful,  serous  oozing,  adenitis. 

(b)  Slow  growth,  papule,  or  ulcer,  scaly  surface,  under- 
neath being  clear  or  blood-stained  fluid ;  slowly  spreads,  with 
cahexia, 

(c)  Dirt  infection,  brief  incubation,  multiple,  tendency  to 
spread,  more  indurated,  painful,  pus,  sometimes  suppurative 
adenitis. 

(d)  Large  vesicles,  intense  itching  and  burning.  Related 
to  colds  or  gastro-intestinal  disorders.  No  induration,  fades 
in  a  few  days. 

Differentiate  prolapsed  kidney,  recurrent  appendicitis, 
gastritis,  and  nephrolithiasis. 

(a)  Neurasthenia.  Crises  from  twisted  pedicle,  with  nau- 
sea and  vomiting.  Urine  scanty,  later  increased.  Dull  pain 
in  right  hypochondrium  and  lumbar  region.  Belly  wall  re- 
laxed and  movable.  Tumor  discovered  on  bimanual  palpa- 
tion. 

(b)  Dull  pain  in  McBurney's  point,  rigid  rectus,  tense 
walls.  Fixed  point  of  tenderness,  lessened  when  bowels  are 
emptied. 

(c)  Epigastric  pain  and  discomfort  closely  related  to  time 
and  character  of  food  taken. 

(d)  Paroxysm  of  pain  radiating  anteriorly  from  lumbar 
region  to  the  groin.  Hematuria  and  crystals  found.  Kidney 
very  tender  during  paroxysm.     X-Ray  positive. 

Give  the  normal  topographic  outlines  of  the  spleen.  Of 
what  significance  is  the  size  of  the  spleen  in  the  diagnosis 
of  febrile  conditions? 

It  is  ovoid,  and  its  size  is  3  by  5  inches,  the  long  axis  par- 
allel with  the  ribs,  reaching  from  a  point  1%  inches  to  the 
left  of  the  midspinal  line  posteriorly  nearly  to  the  midaxillary 
line  laterally,  lying  alongs  the  9th,  10th  and  11th  ribs  in  the 
left  hypochondrium.     It  is  enlarged  in  febrile  conditions  in 


DIAGNOSIS  AND  PRACTICE.  42i 

proportion  to  the  height  and  duration  of  the  temperature. 
Cholera  and  yellow  fever  are  exceptions. 

Give  the  physical  signs  of  miliary  tuberculosis. 

On  inspection,  rapid  breathing,  emaciation  and  dusky  livid- 
ity.  On  percussion,  resonance  or  hyper-resonance.  On  aus- 
cultation, roughened  breathing,  sometimes  broncho-vesicular, 
the  vesicular  murmur  softer  than  normal.  Fine  or  coarse, 
raoist  or  dry  rales,  and  occasional  pleural  friction  rubs. 

Give  the  topography  of  the  heart.  In  what  condition 
may  the  heart  be  displaced,  (a)  upward,  (b)  downward? 

The  area  of  exposed  normal  cardiac  dullness  is  bounded  by 
a  line  drawn  from  the  level  of  the  4th  cartilage  downward 
along  the  left  edge  of  the  sternum,  and  a  second  line  starting 
from  the  upper  end  of  the  first  and  running  downward  to  a 
point  on  the  left  6th  rib  in  the  parasternal  line.  This  area 
is  a  triangle. 

(a)  Effusions  in  pericardium  or  peritoneum,  tympanites, 
pleuritic  adhesions  as  in  pleurisy,  phthisis,  chronic  intersti- 
tial pneumonia,  right-sided  effusions  or  pneumothorax. 

(b)  Hypertrophy  of  the  right  and  left  ventricles,  emphy- 
sema, thoracic  aneurysms,  or  tumors. 

State  the  diagnostic  value  of  a  microscopic  examination 
of  the  vomitus.     Illustrate. 

Its  value  is  great  in  indicating  any  immediate  or  urgent 
treatment  as  in  hemorrhage  from  gastric  ulcer.  It  shows  the 
extent  of  gastric  digestion,  as  in  mucous  gastritis,  and  helps 
to  diagnose  dilatation  by  the  presence  of  food  taken  a  long 
time  previously.  The  odor  and  color  are  of  value  in  poison- 
ing to  indicate  the  character  of  the  poison  taken,  and  to  insti- 
tute prompt  treatment. 

What  diagnostic  sounds  are  revealed  by  auscultation  in 
(a)  laryngismus  stridulus,  (b)  pneumonitis  (second  stage), 
(a)  pleuritis  (first  stage)? 

(a)  High-pitched  and  prolonged  inspiration,  shortened  ex- 
piration, puerile  breathing,  and  no  rales. 


422  DIAGNOSIS  AND  PRACTICE. 

(b)  Tubular  breathing,  broncophony,  whispering  pectori- 
loquy, and  sometimes  egophouy.  Sharp  second  pulmonic 
sound. 

(c)  Decreased  vesicular  respiration,  grating  friction  rub, 
heard  at  height  of  inspiration. 

Give  the  character  of  the  cough  and  expectoration  in 
acute  catarrhal  bronchitis. 

Early,  the  cough  is  dry,  rough,  hacking  and  painful;  later 
less  frequent  and  not  painful.  Early  the  expectoration  is 
scant  and  frothy;  later  freer,  and  may  be  purulent.  The 
microscope  shows  pus  cells,  desquamated  alveolar  cells,  bac- 
teria, and  occasionally  Dittrich's  plugs. 

Define  dyspnea,  state  the  types,  and  the  causes  of 
dyspnea. 

Dyspnea  is  difficult,  painful  or  laborious  breathing. 

Types :  Paroxysmal,  as  in  asthma ;  constant,  as  in  pneu- 
monia ;  inspiratory,  as  in  croup ;  expiratory,  as  in  emphysema ; 
subjective,  as  in  hysteria ;  objective,  as  in  fevers ;  on  exertion, 
as  in  cardiac  weakness. 

Causes:  Factors  producing  a  diminished  quality  or  quan- 
tity of  arterial  blood ;  those  causing  excessive  pulmonary  stasis 
and  marked  interference  with  the  respiratory  center  in  the 
brain. 

Describe  puerile  respiration,  and  state  its  causes. 

A  harsh,  loud  and  exaggerated  element  of  vesicular  breath- 
ing, more  noticeable  on  expiration.  It  is  normal  before 
puberty,  and  occurs  where  sudden  compensatory  emphy- 
sema is  present,  as  in  lobar  pneumonia  and  pleuritic  effusion. 

Mention  five  modern  instruments  of  precision  in  diag= 
nosis,  and  illustrate  the  use  of   each. 

Sphygmomanometer,  to  indicate  blood  pressure.  Thermom- 
eter, to  record  thermogenic  alterations.  Stethoscope,  to 
localize  and  augment  sounds.  Cyrtometer,  to  measure  the 
chest  dimensions  and  capacity.  Microscope,  to  examine  ex- 
udates and  secretions. 


DIAGNOSIS  AND  PRACTICE.  423 

What  is  the  significance  of  hemorrhage  by  diapedesis? 

This  depends  upon  a  diseased  condition  of  the  vessel  wall 
■with  increased  permeability  and  a  blood  dyscrasia  such  as  is 
seen  in  purpura,  scurvy,  etc.  The  fibrin-forming  powers  of 
the  blood  are  greatly  diminished. 

State  the  symptoms  caused  by  a  biliary  calculus  from 
Its  first  manifestations  till  its  voidence  per  vias  naturales. 

The  earliest  symptoms  are  those  of  dyspepsia.  When  the 
calculus  enters  the  common  duct  it  causes  biliary  colic  and 
sometimes  jaundice.  If  it  becomes  lodged  it  may  cause  in- 
tense jaundice,  biliary  cirrhosis,  or  Charcot's  intermittent 
fever.  If  it  passes  into  the  duodenum  it  may  cause  obstruc- 
tion along  the  course  of  the  bowel  or  gather  concretions  and 
form  an  enterolith.  It  may  lodge  some\yhere  along  the  in- 
testine and  cause  progressive  necrosis  and  a  fistula  result, 
with  or  without  peritonitis. 

Relate  the  physical  signs  in  a  case  of  diffuse  bronchitis. 

Palpation  and  percussion  negative  unless  excessive  con- 
gestion present.  Pulse  accelerated.  Harsh  breathing  near 
bronchi.  Large  and  small  sonorous,  subcrepitant,  sibilant, 
and  some  crepitant  rales  over  both  lungs,  heard  best  poster- 
iorly. 

Give  the  prophylactic  treatment  of  gout. 

As  nearly  as  possible  a  vegetable  diet  should  be  adhered  to. 
.as  animal  food  gives  rise  to  uric  acid.  Water  should  be  par- 
taken of  plentifully.  Alcoholic  and  malt  liquors,  especially 
the  rich,  sweet  wines,  such  as  port,  sherry,  champagne,  should 
be  particularly  prohibited.  Systematic  bathing,  regular  ex- 
ercise in  the  open  air,  avoidance  of  exposure  to  cold  and 
<lampness  are  important. 

At  what  age  is  spasmodic  croup  most  common?  Give 
the  symptoms  and  treatment  of  spasmodic  croup. 

The  disease  is  most  common  in  children  before  the  age  of 
puberty.  The  attack  begins  suddenly,  most  often  at  night. 
The  fir-st  indication  is  usually  a  hoarse  metallic  cough,  fol- 


424  DIAGNOSIS  AND  PRACTICE. 

lowed  by  dyspnea.  In  severe  cases  the  dyspnea  is  so  extreme 
that  cyanosis  of  the  face  and  extremities  occurs.  There  is 
some  elevation  of  temperature.  The  cough  is  unproductive 
at  first,  but  at  the  close  of  the  attack  free  expectoration  may 
occur.  The  child  should  at  once  be  immerse(d  in  a  warm  bath, 
and  an  emetic  promptly  given.  Inhalations  of  steam  are  also 
useful.  Between  the  attacks  the  child  should  have  tonic 
treatment. 

Give  the  etiology,  duration  and  prognosis  of  pertussis. 

It  is  an  infectious  disease  of  early  childhood,  and  common 
between  the  second  and  seventh  year.  The  disease  usually 
lasts  from  four  to  six  weeks.  The  prognosis,  as  a  rule,  is 
favorable,  the  danger  being  due  to  complications. 

Describe  the  treatment  of  biliary  lithiasis. 

The  prophylaxis  consists  in  appropriate  diet,  exercise  and 
general  favorable  hygiene.  In  women  tight  lacing  should  be 
avoided.  Warm  baths,  regular  exercise  in  the  fresh  air,  etc., 
should  be  recommended.  The  patient  should  avoid  indul- 
f^ence  in  sweet  and  starchy  foods.  Constipation  should  be 
corrected.  Massage  has  been  strongly  advised.  For  the 
treatment  of  the  attack  hot  fomentations  should  be  applied 
over  the  liver.  For  the  pain  hypodermic  injections  of  mor- 
phine give  relief.  If  the  condition  is  not  relieved  by  medical 
means,  if  the  jaundice  persist,  and  especially  if  symptoms  of 
Charcot's  fever  appear,  surgical  interference  should  be  re- 
sorted to. 

Give  the  etiology  and  treatment  of  St.  Vitus'  dance. 

Chorea  is  a  disease  of  childhood,  although  it  may  occur  at 
any  age.  Females  are  most  often  attacked,  and  the  disease  is 
more  common  in  the  temperate  climate.  It  is  most  prevalent 
in  the  spring  months.  Acute  rheumatic  fever  has  been  noted 
as  an  exciting  cause  in  a  large  number  of  eases.  Fright, 
shock  and  worry  are  predisposing  causes.  It  may  be  due  to 
reflex  causes,  such  as  intestinal  worms,  eye  strain,  nasal  dis- 
ease and  sexual  disorders.  The  treatment  consists  in  long 
hours  of  rest,  especially  in  bed.     If  the  child  be  attending 


DIAGNOSIS  AND  PRACTICE.  425 

school  it  had  better  discontinue  and  remain  at  home.  The 
diet  should  be  simple,  meats  and  highly-seasoned  foods  should 
be  excluded.  Arsenic,  antipyrine,  bromide  of  zinc  and  qui- 
nine and  the  salicylates  are  the  most  useful  drugs. 

Give  the  etiology,  symptoms  and  treatment  of  cirrhosis 
of  the  liver. 

The  disease  occurs  most  often  in  the  male  sex,  and  is  very 
frequently  due  to  alcohol.  In  the  newborn  the  affection  is 
due  to  hereditary  syphilis.  The  next  most  important  causes 
are  acquired  syphilis,  malaria  and  other  infectious  diseases, 
such  as  cholera,  enteric  fever  and  scarlet  fever.  Gout  and 
rickets  also  give  rise  to  it.  The  disease  may  begin  without 
prodromes,  except  in  the  case  of  topers  who  present  a  long 
history  of  gastro-intestinal  catarrh.  Early  in  the  course  of 
the  affection  there  may  be  some  slight  enlargement  of  the 
liver.  In  the  fully  established  disease  the  organ  is  dimin- 
ished in  size.  Of  decided  diagnostic  import  is  an  early  atro- 
phic change  in  the  right  lobe  of  the  liver,  which  in  some  cases 
can  scarcely  be  felt  in  the  abdomen.  Jaundice  is  absent  as  a 
rule.  The  most  characteristic  symptoms  relate  to  the  disturb- 
ance of  the  circulation  in  the  portal  vein,  or  to  the  diminished 
function  in  the  atrophied  cells  of  the  liver,  or  they  depend 
upon  a  combination  of  these  two  conditions.  One  of  the  most 
prominent  signs  is  ascites.  Even  before  this  the  effect  of 
congestion  of  the  mucous  membranes  of  the  stomach  and 
bowels  may  be  noted  by  hematemesis  and  enterrhagia,  which 
occur  in  the  course  of  this  affection.  Hemorrhoids  occur. 
The  spleen  is  enlarged.  The  cutaneous  veins  of  the  abdomen 
are  often  greatly  enlarged.  The  urine  is  diminished  in 
amount  and  is  of  low  specific  gravity,  frequently  reddish  in 
color.  The  temperature  is  normal  or  subnormal.  The  gen- 
eral nutrition  suffers  greatly,  and  the  patient  loses  flesh.  The 
treatment  consists  in  abstaining  from  alcohol.  Potassium 
iodide  and  mercury  are  of  use  in  the  syphilitic  form.  The 
bowels  .should  be  carefully  regulated,  and  when  ascites  be- 
comes i)romiiient.  paracentesis  abdominis  becomes  necessary. 


426  DIAGNOSIS  AND  PRACTICE. 

Give  the  etiology  of  tetanus. 

The  disease  occurs  in  either  sex  and  at  any  age.  It  may 
result  from  a  wound  in  any  part  of  the  body,  and  sometimes 
^\^thout  apparent  trauma.  It  occurs  most  often  from  wounds 
that  are  exposed  to  dirt  and  filth.  The  exciting  eause  is  the 
bacillus  of  tetanus  described  by  Kitasato. 

Give  the  treatment  of  sciatica. 

Rest  by  means  of  splinting  the  limb  is  important.  Atten- 
tion must  be  directed  to  the  cause  of  the  disease.  If  of  rheu- 
matic origin  the  salicylates  are  of  value.  Phenacetine,  anti- 
pyrine  and  other  members  of  the  coal-tar  group  are  of  value ; 
in  severe  cases,  however,  morphine  is  necessary.  Surgical 
measures  should  only  be  resorted  to  after  all  forms  of  medical 
relief  have  failed. 

State  the  varieties,  causes  and  prognosis  of  angina  pec= 
toris. 

True  angina  pectoris  and  pseudo  angina  pectoris.  Occlu- 
sion of  the  coronary  arteries  and  sclerosis  are  important  fac- 
tors. The  true  form  occurs  after  middle  life,  and  in  the  male 
«ex ;  the  pseudo  form  occurs  most  frequently  in  young  women, 
in  connection  with  hysteria  and  neurasthenia.  The  prog- 
nosis in  the  true  form  is  very  unfavorable ;  in  the  pseudo  form 
it  is  favorable. 

How  should   insolation   (sunstroke)    be  treated? 

The  treatment  of  thermic  fever  consists  in  the  application 
■of  cold  to  the  surface  of  the  body,  preferably  in  the  form  of 
an  ice  bath  or  ice  rubbing.  The  cold  pack  is  sometimes  sub- 
stituted. The  bath  is  commonly  continued  until  the  temper- 
ature reaches  the  normal  point.  Ice-water  enemata  may  also 
be  employed.  Measures  should  also  be  taken  to  guard  the 
heart.  For  this  purpose  strychnine,  digitalis  and  alcohol 
iire  useful. 

Give  the  treatment  and  prognosis  of  erysipelas. 

Cold  water  should  be  liberally  administered  to  the  patient, 
and  cold  sponging,  especially  if  the  temperature  is  high,  is  of 


DIAGNOSIS  AND  PRACTICE.  427 

distinct  advantage.  Ice  cloths  are  also  the  best  treatment 
for  the  eruption.  They  should  be  frequently  renewed.  An 
ointment  of  ichthyol  and  lanolin  is  also  used  for  this  purpose. 
The  administration  of  tincture  of  the  chloride  of  iron  in  full 
doses  is  the  general  method  of  treating  erysipelas.  When 
the  nervous  symptoms  become  prominent,  and  in  the  aged  or 
cachectic,  bold  stimulation  is  necessary;  alcohol  is  best  for 
this  purpose.  If  the  pain  be  severe  morphine  shuld  be  re- 
sorted to.  Anti-streptoeoccic  serum  may  be  beneficial,  and 
should  always  be  resorted  to  in  malignant  cases. 

In  simple,  uncomplicated  cases  occurring  in  those  in  pre- 
vious good  health  the  prognosis  is  favorable.  The  prognosis 
should  be  regarded  as  serious  when  erysipelas  occurs  as  a 
complication  of  any  other  malady,  or  when  it  results  from 
surgical  accidents  or  occurs  in  the  puerperal  state.  It  is 
always  serious  in  alcoholics  and  cachectics. 

State  the  etiology  and  prophylaxis  of  biliary  calculi. 

In  a  majority  of  cases  they  are  found  in  persons  of  thirty 
and  over,  and  they  occur  more  frequently  in  the  female  than 
in  the  male  sex.  Catarrh  of  the  bile-ducts  and  gall  bladder 
may  lead  to  stagnation  of  bile  and  to  an  increase  in  the  amount 
of  cholesterin.  Farinaceous  foods  may  give  rise  to  the  for- 
mation of  gall-stones ;  in  diseases  in  which  nitrogenous  food 
is  largely  partaken  of.  as  in  diabetes,  gall-stones  are  rarely 
found.  They  are  formed  most  frequently  in  the  gall-bladder. 
They  may  occur  in  the  larger  gall-ducts,  and,  rarely,  even  in 
the  smaller  biliary  passages  of  the  liver.  The  prophylaxis 
consists  in  appropriate  diet,  exercise  and  general  favorable 
hygiene.  In  women  tight  lacing  should  be  avoided.  Warm 
baths,  regular  exercise  in  the  fresh  air,  etc.,  should  be  recom- 
mended. The  patient  should  avoid  indulgence  in  sweets  and 
starchy  foods.  Constipation  should  be  corrected.  This  may 
best  be  done  by  the  use  of  waters,  such  as  Carlsbad.  Massage 
has  been  strongly  advised. 

What  is  chronic  hydrocephalus? 

As  a  rule  the  child's  head  begins  to  increase  in  size  soon 


428  DIAGNOSIS  AND  PRACTICE. 

after  birth,  or  it  may  even  be  greatly  enlarged  at  birth.  There 
is  irritability  and  restlessness,  and  much  impairment  of  the 
general  nutrition;  the  child  does  not  grow  as  is  usual  with 
normal  children,  even  though  the  appetite  be  good.  Mental 
development  is  tardy,  and  as  a  rule  the  child  does  not  learn 
to  walk.  Ocular  phenomena  are  present,  such  as  strabismus, 
and  occasionally  optic  atrophy.  Within  a  few  years  vomiting, 
coma  and  convulsions  appear.  Death  usually  takes  place 
from  exhaustion. 

Give  the  etiology  and  treatment  of  anthrax. 

This  is  a  widespread  disease  in  animals,  occurring  all  over 
the  world.  The  affection  is  conveyed  to  man  as  the  result  of 
the  handling  of  wood  or  hides,  rarely  by  direct  inoculation 
from  the  bites  of  insects  that  have  fed  on  animals  that  have 
died  of  the  disease.  It  is  a  very  rare  affection  in  man.  Cer- 
tain occupations  predispose  to  it,  such  as  those  of  stablemen, 
tanners,  butchers,  shepherds  and  wool-sorters.  The  exciting 
cause  is  the  bacillus  of  anthrax.  It  is  important  that  the 
pustules  should  be  treated  surgically,  the  site  of  inoculation 
being  destroyed  by  bichloride  of  mercury,  carbolic  acid  or  the 
actual  cautery.  Constitutional  treatment  consists  in  the  use 
of  quinine,  iron,  strychnine  and  alcohol. 

Give  the  treatment  of  catarrhal  pneumonitis. 

Wlieu  the  temperature  becomes  high,  cyanosis  shows  itself 
and  somnolence  is  threatened,  and  a  warm  bath  with  cold  effu- 
sion to  the  head  is  useful.  Alcohol  is  valuable  as  a  circulatory 
stimulant.  Inhalations  of  steam  are  of  value.  In  strong 
children  in  whom  there  is  great  secretion  in  the  bronchial 
tubes  which  is  brought  up  with  difficulty,  emetics  may  be  used 
from  time  to  time,  but  these  should  not  be  continued  through- 
out the  course  of  the  disease.  It  is  dangerous  to  administer 
narcotics  to  young  children.  Stimulating  expectorants,  such 
as  the  salts  of  ammonia,  are  often  useful.  Minute  doses  of 
strychnine  and  inhalations  of  oxygen  are  of  benefit.  A  mild 
purge  at  the  onset  frequently  gives  great  relief.  The  diet 
should  be  a  light  and  nutritious  one. 


DIAGNOSIS  AND  PRACTICE.  429 

What  is  the  prognosis  as  to  the  cure  of  epilepsy?  Give 
the  treatment  of  epilepsy. 

True  epilepsy  is  an  incurable  affection.  Much  may  be  done 
to  diminish  the  number  and  severity  of  the  attacks,  but  a  true 
cure  is  rarely  met  with.  In  the  treatment  it  is  important  to 
relieve  the  cause  if  possible.  It  is  best  to  endeavor  to  treat 
the  epileptic  in  a  colony,  in  which  he  may  have  an  out-door 
occupation.  The  bowels  should  be  regulated,  the  diet  should 
consist  of  meat  sparingly,  fruit,  cereals  and  vegetables.  The 
best  results  have  been  obtained  from  the  use  of  the  bromides. 

What  cutaneous  diseases  may  occur  as  complications  of 
saccharine  diabetes? 

Boils,  carbuncles,  erythema,  eczema,  especially  of  the  geni- 
tals, purpura,  cellulitis  and  gangrene. 

What  is  hemophilia?      How  should  it  be  treated? 

This  is  a  disease  characterized  by  a  tendency  to  hemorrhage, 
which  is  often  uncontrollable,  and  it  is  due  to  a  deficiency  in 
the  coagulability  of  the  blood.  The  coagulation  is  retarded, 
and  frequently  in  this  condition  the  blood  does  not  coagulate 
in  less  than  from  thirty  to  fifty  minutes.  The  prophylaxis  is 
important ;  wounds  and  operations  should  be  avoided  in  a  per- 
son suspected  to  be  a  bleeder.  When  the  bleeding  is  from  a 
free  surface  and  easy  of  access,  compression  and  rest  should 
be  tried.  Ice.  locally,  is  of  value.  Calcium  chloride  and  per- 
chloride  of  iron  are  recommended  by  many.  Gelatine,  collo- 
dion and  extract  of  the  suprarenal  capsule  may  be  found 
useful  when  applied  to  the  bleeding  surface.  Freshly  drawn 
blood  from  a  healthy  person  may  be  employed  as  an  appli- 
cation. 

Describe  the  treatment  of  purulent  pleurisy. 

The  aspirator  should  be  used,  and  drainage  should  be  as 
free  as  possible.  If  the  pus  does  not  flow  through  the  needle 
a  surgical  operation  is  necessary. 


430  DIAGNOSIS  AND  PRACTICE. 

Describe  the  treatment  and  prophylaxis  of  nephrolith- 
iasis. 

The  treatment  consists  in  relieving  the  pain  during  an 
attack  of  renal  colic,  which  is  best  accomplished  by  a  hypo- 
dermic of  morphine  or  by  the  inhalation  of  chloroform.  Hot 
baths  and  hot  fomentations  to  the  loins  are  useful.  Fluids 
should  be  freely  partaken  of.  For  uric  acid  calculi,  piper- 
azin,  urotropin,  and  the  salts  of  lithia  are  of  value.  The 
waters  of  various  mineral  springs  are  valuable,  such  as  Carls- 
bad, Ems,  Kissingen.  Surgical  interference  is  sometimes 
necessary. 

How  should  cholera  morbus  be  treated? 

Absolute  rest  in  bed  is  necessary.  Food  should  be  given 
sparingly,  and  it  had  better  be  withheld  for  some  time  if 
vomiting  be  frequent.  Sterilized  milk  and  animal  broths  may 
be  administered  sparingly.  Local  sinapisms  and  hot  turpen- 
tine stupes  are  of  benefit  to  allay  vomiting.  At  the  onset  of 
the  disease  it  is  good  practice  to  give  a  purge.  The  remedy 
for  the  condition  is  opium  in  some  form.  Later  in  the  course 
of  the  affection  bismuth  and  antiseptics  which  act  on  the 
intestinal  tract  are  of  value. 

What  is  the  treatment  of  spasmodic  stricture  of  the 
esophagus? 

Dilatation  with  the  esophageal  bougie  is  of  value.  Remedies 
to  act  upon  the  nervous  system  and  tonics  are  of  use.  The 
general  hygiene  of  the  patient  should  be  carefully  looked 
after. 

Give  the  treatment  of  hematemesis. 

Absolute  rest  in  bed.  Food  and  drink  should  be  stopped. 
For  the  thirst  small  pellets  of  ice  may  be  taken  in  the  mouth. 
Opium  and  ergot  hypodermically  are  the  best  remedies.  Tan- 
nic acid  by  the  mouth  should  be  used. 

Describe  the  treatment  of  rachitis. 

The  child  should  have  the  best  of  food,  and  if  the  mother 
cannot  nurse  it  a  wet-nurse  should  be  procured.     Abundance 


DIAGNOSIS  AND  PRACTICE.  431 

of  fresh  air  and  sunshine  are  essential.  Daily  warm  bathing- 
is  necessary.  The  child  should  not  be  encouraged  to  walk. 
The  remedies  that  have  proven  most  effective  are  phosphorus, 
cod-liver  oil  and  the  syrup  of  the  iodide  of  iron. 

Give  the  treatment  of  ulcer  of  the  stomach. 

Rest  in  bed  is  most  important,  even  in  the  mildest  eases. 
Food  should  be  withheld  from  the  stomach  for  some  time,  rec- 
tal alimentation  being  resorted  to.  Milk  is  the  best  food,  and 
may  be  given  either  hot  or  cold.  External  applications  over 
the  stomach,  such  as  hot  poultices  frequently  renewed,  are  of 
value.  Among  the  most  useful  of  the  many  drugs  that  have 
been  recommended  is  bismuth ;  this  remedy  should  be  em- 
ployed in  large  doses.  Salol,  oxide  of  silver,  carbonate  of 
soda,  carbolic  acid  and  cocaine  are  also  highly  recommended. 
If  there  be  great  pain  opium,  and  sometimes  cannabis  indica 
are  useful. 

Give  the  symptoms  of  (a)  acute  lead  poisoning,  (b) 
chronic  lead  poisoning. 

( a)  In  acute  lead  poisoning  the  symptoms  may  come  on  in  a 
few  weeks.  Rapid  and  marked  anemia  is  usually  the  earliest 
symptom.  Constipation,  which  is  followed  by  excessive  diar- 
rhea, vomiting,  abdominal  tenderness  and  distension  are  pres- 
ent. The  abdomen  as  a  rule,  is  hard  and  distended.  There 
is  colic  of  the  severest  type  over  the  entire  abdomen.  The 
paroxysms  are  of  gradual  onset  and  increase  in  severity.  The 
pain  is  relieved  by  deep  pressure.  The  temperature,  as  a  rule, 
is  subnormal,  (b)  The  symptoms  of  chronic  lead  poisoning 
are  due  to  the  prolonged  absorption  of  lead  in  small  quantities. 
The  anemia  may  be  profound,  showang  a  marked  decrease  in 
the  red  blood-cells,  with  a  corresponding  decreavse  in  the  hem- 
oglobin. There  is  wasting  of  the  muscles  and  a  peculiar  yel- 
low complexion,  which,  however,  is  not  due  to  the  deposit  of 
bile  pigment.  Along  the  border  of  the  gums,  usually  most 
marked  under  the  incisor  teeth,  is  a  bluish-black  line.  Trem- 
ors occur  from  time  to  time.  There  is  a  metallic  taste  in  the 
mouth,   coated   tongue,   fetid  breath,   marked   dyspepsia  and 


432  DIAGNOSIS  AND  PRACTICE. 

obstinate  constipation.  Lead  colic  is  particularly  marked. 
The  pain,  as  a  rule,  is  more  severe  in  the  afternoon  and  at 
night.  Occasionally  paroxysmal  pains  occur  in  the  joints 
without  swelling,  redness  or  fever.  An  important  symptom 
is  lead  paralysis.  This  most  frequently  occurs  as  wrist-drop, 
the  extensors  being  particularly  affected.  Occasionally  cere- 
bral symptoms  develop,  this  condition  being  known  as  lead 
encephalopathy. 

Give  the  treatment  of  suppurative  hepatitis. 

The  treatment  consists  in  the  early  evacuation  of  the  ab- 
scess in  suitable  cases.  Purging  with  calomel  or  salts  is 
recommended.  Opium  is  best  to  relieve  pain.  When  the 
septic  phenomena  are  marked,  free  stimulation  should  be  re- 
sorted to,  whiskey  and  strychnine  giving  good  results.  Qui- 
nine is  often  of  use.  For  the  anemia,  iron  and  arsenic  should 
be  administered.     The  diet  should  be  light  and  nutritious. 

What  is  uremia  and  how  should  it  be  treated? 

Uremia  is  a  clinical  condition  due  to  acute  or  chronic  dis- 
ease of  the  kidney  or  of  its  conducting  apparatus.  Depend- 
ing upon  whether  the  symptoms  arise  rapidly  or  suddenly  or 
whether  they  are  more  insidious,  the  condition  is  known  as 
acute  or  chronic  uremia.  In  young  subjects  with  slow  pulse 
and  high  arterial  tension  bleeding  is  indicated,  and  should  be 
followed  by  hypodermoclysis  of  a  normal  salt  solution.  In- 
travenous injections  of  a  normal  salt  solution  are  often  indi- 
cated. Purging  by  croton  oil  and  broken  doses  of  calomel 
is  useful.  For  the  convulsions,  chloral  and  morphine  hypo- 
dermically  are  the  most  reliable  agents.  Sweating  should  be 
induced  by  a  hot  pack  or  by  some  similar  method.  The  ad- 
ministration of  pilocarpine  is  accompanied  with  danger  on 
account  of  its  depressing  effect  upon  the  heart. 

How  should  acute  nephritis  accompanying  or  following 
scarlet  fever  be  treated? 

Absolute  rest  in  bed  is  important.  It  is  well  to  put  the 
patient  on  an  absolute  milk  diet.     Some  of  the  alkaline  min- 


DIAGNOSIS  AND  PRACTICE.  433 

eral  waters,  such  as  Seltzer  and  Vichy,  may  be  mixed  with 
the  milk.  Daily  sponging  with  warm  water  and  gentle  fric- 
tion of  the  skin  are  of  use.  Calomel  in  fractional  doses  is 
useful,  and  may  be  followed  by  a  saline,  even  if  there  be  no 
tendency  to  constipation.  Some  of  the  diuretics  may  be  used, 
such  as  citrate  of  potash  or  benzoate  of  soda.  Iron  in  some 
form  is  useful,  and  Basham's  mixture  is  often  administered. 

Hou  should  edema  of  the  glottis  be  treated? 

The  treatment  is  that  of  dropsy  occurring  in  other  parts  of. 
the  body.  Surgical  treatment,  such  as  scarification,  intuba- 
tion, tracheotomy,  etc.,  is  often  necessary.  Adrenalin  locally 
will  act  promptly  and  effectively. 

Name  one  important  complication  and  one  important 
sequel  of  typhoid  fever. 

An  important  complication  of  typhoid  fever  is  hemorrhage 
from  the  bowels.  An  important  sequel  is  phlebitis,  which 
most  frequently  occurs  in  the  left  leg. 

What  is  dysphagia,  and  with  what  pathological  condi=- 
tion  is  it  associated? 

Dysphagia  is  difficulty  or  pain  in  swallowing.  It  may  be 
due  to  causes  in  the  mouth  and  fauces,  such  as  glossitis,  cancer 
of  the  tongue,  to  various  forms  of  stomatitis,  tonsillitis  and 
pharyngitis.  Some  of  the  exanthemata,  such  as  scarlet  fever 
and  variola,  give  rise  to  lesions  of  the  throat,  diphtheria, 
spasm  or  paralysis  of  the  pharynx,  disease  of  the  larynx,  dis- 
ease of  the  esophagus,  such  as  stricture,  cancer,  etc.  Finally, 
from  pressure  from  the  outside,  such  as  from  an  enlarged 
thyroid  gland,  thoracic  aneurysm,  mediastinal  tumor,  etc.. 
and  fi'oin  pleural  and  pericardial  effusion. 

How  would  aneurysm  of  the  abdominal  aorta  affect  the 
dorsalis  pedis  artery  pulse  as  compared  with  the  radial- 
pulse? 

The  pulse  of  the  dorsalis  pedis  artery  compared  with  the 
radial  pulse  would  be  small  and  delayed. 
28 


434  DIAGNOSIS  AND  PRACTICE. 

What  conditions  predispose  to  cerebral  hemorrhage? 

Heredity  is  important;  many  individuals  inherit  the  apo- 
plectic constitution.  It  is  a  disease  of  middle  life,  and  more 
common  in  the  male  sex.  Diseases  of  the  bloods  vessels  are 
important  factors.  It  may  follow  the  infectious  fevers  and 
diseases  producing  disturbances  of  the  blood.  Embolism  is 
an  important  factor.  Hypertrophy  of  the  heart,  exertion  or 
excitement  frequently  cause  rupture  of  the  diseased  blood 
vessels. 

What  are  the  causes  of  endocarditis? 

The  greatest  number  of  cases  are  the  result  of  rheumatic 
fever.  Chorea  is  also  a  cause.  The  acute  exanthemata  also 
give  ri^e  to  it,  also  pneumonia,  erysipelas,  sepsis,  puer- 
peral diseases,  and  sometimes  gonorrhea.  Tuberculosis,  gout, 
renal  disease  and  diabetes  are  etiological  factors.  Trauma 
has  also  been  given  as  a  cause.  It  occurs  in  fetal  life.  It 
may  sometimes  be  secondary,  from  extension  of  the  disease 
from  the  myocardium  or  aorta. 

Differentiate  between  cerebral  vomiting  and  gastric 
vomiting. 

Cerebral  vomiting  occurs  without  nausea,  often  with  a  clean 
tongue,  and  is  not  related  to  the  taking  of  food.  In  gastric 
vomiting  there  is  the  history  of  some  gastro-intestinal  affec- 
tion. The  tongue  is  coated,  and  there  is  always  considerable 
nausea  and  much  retching. 

Give  the  characteristic  differences  between  diabetes 
insipidus  and  diabetes  mellitus. 

In  diabetes  insipidus  the  urine  is  of  low  specific  gravity, 
never  over  1010 ;  there  is  no  sugar  present,  no  itching  of  the 
skin  and  genitalia,  no  hunger,  no  tendency  to  the  formation 
of  carbuncles  or  boils.  In  diabetes  mellitus  the  urine  is  of 
high  specific  gravity,  1020  and  over,  sugar  is  present  in  the 
urine,  there  is  itching  of  the  skin,  great  hunger,  tendency  to 
formation  of  boils,  loss  of  weight,  and  frequently  an  etherial 
odor  of  the  breath. 


DIAGNOSIS  AND  PRACTICE.  435 

Give  the  cause  of  vertigo. 

Vertigo  occurs  in  the  course  of  neurasthenia  and  lithemia, 
from  gastric  disorders,  from  arteriosclerosis,  valvular  disease 
of  the  heart  and  aneurysm,  from  Meniere's  disease,  from 
reflex  causes,  such  as  disease  of  the  eye,  nose  and  larynx.  It 
also  occurs  in  many  nervous  diseases,  such  as  epilepsy,  etc. 

Describe  pyuria  and  state  its  import. 

Pyuria  is  pus  in  the  urine,  and  is  an  important  symptom 
in  many  diseases  of  the  urinary  tract,  from  the  kidney  to  the 
end  of  the  urethra.  It  is  present  in  urethritis,  cystitis,  ure- 
teritis, pyelitis  and  pyelonephritis.  Pus  may  be  caused  by 
rupture  of  an  abscess  in  the  urinary  tract  (especially  the 
bladder)  ;  this  may  occur  in  salpingitis,  abscess  of  the  ovary, 
extra-uterine  pregnancy,  cysts  of  various  kinds,  psoas  and 
other  forms  of  abscess,  etc. 

Describe  leukemia  and  mention  the  pathological  changes 
occuring  in  this  disease. 

Leukemia  is  a  disease  in  which  the  white  blood  corpuscles 
are  greatly  increased  in  number ;  the  percentage  of  the  various 
forms  also  differ  greatly  from  the  normal.  It  is  character- 
ized anatomically  by  changes  in  the  spleen,  lymphatic  glands 
or  bone  marrow,  singly  or  combined.  In  the  splenomedullary 
form  the  spleen  is  greatly  enlarged,  and  it  may  weigh  ten 
pounds  or  more.  The  capsule  is  thickened,  and  the  surface 
of  the  organ  somewhat  irregular.  On  section  it  is  quite  firm. 
The  color  of  the  pulp  is  reddish-brown.  Infarcts  are  common. 
The  gross  appearance  of  the  blood  is  altered,  occasionally 
being  milky  in  character,  the  specific  gravity  is  decreased,  the 
alkalinity  is  somewhat  diminished,  and  coagulation  is  slightly 
retarded.  The  leukocytes  show  a  great  increase  in  number, 
from  250,000-500,000  or  more  per  cmm.  In  the  lymphatic 
variety  groups  of  lymph  glands  are  enlarged,  owing  to  hyper- 
j)lasia  of  the  lymphoid  cells,  and  the  spleen  is  slightly  in- 
creased in  size.  The  gross  appearance  of  the  blood  may  show 
very  slight  change  or  resemble  the  variety  just  described.  The 
lonkofvtos  arc  also  groatlv  increased  in  number,  but  not  to 


436  DIAGNOSIS  AND  PRACTICE. 

the  extent  that  they  are  in  the  splenomedullary  form.  Ex- 
amination of  the  stained  films  shows  an  enormous  increase 
in  the  lymphocytes. 

Give  the  symptoms  indicative  of  impacted  gallstone. 

When  the  gallstone  has  become  impacted  there  is  an  arrest 
of  the  pain.  Jaundice  is  marked,  the  urine  shows  bile  pig- 
ments, and  the  stools  are  clay-colored.  There  is  hepatic  inter- 
mittent fever,  sometimes  called  Charcot's  fever.  This  con- 
sists of  high  temperature,  chills  and  sweating.  While  this 
fever  is  paroxysmal,  it  does  not  show  the  regularity  of  a 
malarial  attack. 

Give  the  treatment  of  yellow  fever. 

Disinfection  of  the  person  and  all  eifects.  Strict  quaran- 
tine. A  mild  cathartic  may  be  given  at  the  onset  with  advan- 
tage. Vomiting  and  gastric  irritability  may  be  treated  by 
the  administration  of  carbolic  acid,  cocaine  or  broken  doses 
of  calomel.  The  fever  should  be  treated  by  cold  applications 
to  the  head  and  cold  sponging.  For  the  pain  opium  in  some 
form  is  useful.  Strychnine  is  valuable  as  a  cardiac  tonic. 
For  the  hemorrhage,  opium,  ergot  and  suprarenal  extract 
may  be  administered. 

Outline  appropriate  treatment  for  asiatic  cholera. 

Complete  isolation  of  the  sick  and  thorough  disinfection  of 
all  discharges  and  all  articles  of  clothing  are  absolutely 
necessary.  Efficient  quarantine  must  be  established.  All 
milk  and  water  should  be  boiled,  and  no  raw  fruit  or  vege- 
table should  be  taken.  In  the  stage  of  premonitory  diarrhea 
it  is  considered  good  practice  to  administer  a  prompt  laxative. 
If  there  be  great  pain  opium  may  be  given  hypodermically. 
Salol  and  guaiacol  carbonate  may  be  given  from  time  to  time 
as  intestinal  antiseptics.  In  the  stage  of  serous  diarrhea  the 
patient  should  be  wrapped  in  flannels  and  external  heat  ap- 
plied to  the  body.  If  there  be  cramp,  friction  of  the  muscles 
is  useful.  Fluids  should  only  be  allowed  in  very  small  quan- 
tities.    Enteroclysis  should  be  used  in  this  stage.     When  col- 


DIAGNOSIS  AND  PRACTICE. 

lapse  sets  in,  hypodermoclysis  of  a  normal  salt  solution  should 
be  given.  Strychnine  may  be  given  by  the  skin,  but  it  must 
be  remembered  that  as  absorption  is  slow,  accumulation  may 
occur. 

What  are  the  causes  and  treatment  of  palpitation  of  the 
heart? 

This  may  be  due  to  reflex  causes,  such  as  diseases  of  the 
stomach,  disease  of  the  genito-urinary  apparatus,  and  sexual 
excesses.  Toxic  causes  may  give  rise  to  it,  such  as  the  abuse 
of  alcohol,  tobacco,  tea  and  coffee.  Gout  and  anemia  are 
productive  features,  and  the  condition  occurs  in  inanition  and 
marasmus  and  in  exophthalmic  goitre.  Finally,  it  may  be  due 
to  disease  of  the  heart  itself.  The  treatment  consists  in  re-, 
moving  the  cause,  if  possible,  and  in  then  treating  sympto- 
matically.  Rest  in  the  recumbent  posture  and  an  ieebag  over 
the  heart  are  useful. 

What  are  the  causes  and  symptoms  of  dilatation  of  the 
stomach? 

The  dilatation  may  be  acute  or  chronic.  It  may  be  due  to 
obstruction  of  the  pyloric  end  of  the  stomach,  such  as  con- 
genital stenosis,  the  cicatrices  resulting  from  gastric  ulcer, 
and  from  tumors,  the  most  common  being  malignant.  Motor 
insufificiency  of  the  stomach  may  give  rise  to  dilatation;  this 
may  result  from  overeating  or  drinking,  and  frequently  occurs 
in  beer  drinkers.  The  symptoms  are  general  feebleness,  ane- 
mia, emaciation,  thirst,  scanty  urine,  sallow  and  hollowed  face, 
flabby  coated  tongue,  pyrosis,  chilliness,  cyanosis,  subnormal 
temperature  and  nervous  symptoms.  Pain  and  vomiting  are 
always  present.  The  outline  of  the  stomach  may  be  demon- 
strated by  means  of  the  X-ray. 

What  is  scurvy,  how  should  it  be  prevented  and  treated? 

Scurvy  is  an  affection  due  to  improper  food,  characterized 
by  anemia,  by  swollen,  tender  and  bleeding  gums,  by  mani- 
festations of  purpura  and  by  great  prostration.  The  preven- 
tion of  the  condition  is  accomplished  by  the  use  of  anti-scor- 


438  DIAGNOSIS  AND  PRACTICE. 

butic  food.  In  the  treatment,  antiseptic  mouth  washes  are  of 
use.  Fresh  vegetables  should  be  administered.  Lemon-juiee 
is  very  valuable,  as  are  also  bitter  tonics. 

Give  in  detail  the  treatment  of  diphtheria. 

The  prophylaxis  is  highly  important,  the  disease  being  very 
contagious  and  easily  transmitted.  The  patient  should  be 
strictly  isolated.  Efficient  disinfection  is  also  necessary. 
The  food  must  be  nutritions  and  easily  digested.  If  the 
patient  cannot  swallow,  rectal  alimentation  must  be  resorted 
to.  Alcohol  is  necessary,  and  must  be  given  freely,  even  in 
mild  cases.  Tha  membrane  must  not  be  removed.  Antiseptic 
and  soothing  applications  are  employed ;  inhalations  of  quick- 
lime and  steam  in  all  cases  in  which  there  is  danger  of  inva- 
sion of  the  larynx  are  useful.  Hydrogen  dioxide  in  solution 
is  serviceable  as  a  mouth  wash.  Internally,  the  tincture  of 
chloride  of  iron  may  be  given  in  medium  doses.  Calomel  or 
corrosive  sublimate  in  appropriate  doses  are  useful.  The 
antitoxin  treatment,  however,  is  the  most  important.  The 
dose  in  individual  cases  varies;  3,000  antitoxin  units  may 
be  given  at  a  dose,  but  this  may  be  increased  in  severe 
cases  and  repeated.  In  laryngeal  cases  intubation  and  tra- 
cheotomy may  have  to  be  resorted  to. 

What  is  the  prognosis  of  suppurative  nephritis  secondary 
to  cystitis?     Outline  the  treatment  of  the  condition. 

The  prognosis  is  unfavorable,  and  the  treatment  is  surgical. 

Give  the  etiology  of  tubercular  peritonitis  and  the  treat= 
ment. 

The  disease  appears  at  all  ages,  but  it  is  most  common  in 
childhood.  Males  are  more  frequently  attacked  than  females, 
and  it  is  more  often  met  with  in  the  negro  than  in  the  white 
race.  It  is  also  found  associated  with  intestinal  or  mesenteric 
tuberculosis.  The  condition  may  be  primary  in  the  perito- 
neum, and  may  be  confined  solely  to  this  membrane.  A  com- 
mon mode  of  infection  is  through  the  intestines;  this  may  also 
occur  through  the  lymphatics  or  by  extension  from  the  pleura 


DIAGNOSIS  AND  PRACTICE.  439 

or  the  pericardium.  It  is  often  of  the  miliary  variety,  but 
-also  of  the  chronic  ulcerative  and  chronic  fibroid  forms.  The 
modern  treatment  of  this  condition  is  surgical,  the  best  results 
liaving  been  obtained  by  opening  the  abdomen  and  producing 
adhesions. 

Outline  a  plan  of  treatment  of  typhus  fever. 

The  prophylaxis  is  of  the  greatest  importance.  An  abund- 
ant supply  of  good  food,  fresh  air  and  free  ventilation  are 
important.  Stimulation  is  necessary  on  account  of  the  severe 
prostration.  If  hyperpyrexia  occur  the  cold  bath  should  be 
resorted  to.  Strychnine  may  be  necessary  as  a  respiratory 
and  cardiac  stimulant.  Complications  are  treated  as  they 
arise.  The  constipation  must  be  relieved  by  enemata,  and  in 
convalescence  tonics  should  be  administered. 

Give  the  treatment  of  pyelitis. 

The  patient  must  be  kept  in  bed  and  protected  against  cold. 
A  bland  diet  should  be  given  and  the  alkaline  mineral  waters 
freely  used.  Application  of  heat  to  the  renal  region  should 
he  resorted  to.  Warm  baths  are  grateful  to  the  patient. 
Opium  in  some  form  to  relieve  the  pain  is  necessary.  In 
chronic  pyelitis  astringents  are  indicated,  such  as  acetate  of 
lead.  Salol  and  methylene  blue  are  sometimes  found  of  ben- 
•efit.  Surgical  interference  is  necessary  if  hydronephrosis  or 
pyelonephrosis  is  present. 

Mention  the  most  reliable  remedy  for  pulmonary  hem= 
orrhage. 

Rest  in  bed,  abstaining  from  food  and  drink,  an  ice-bag 
applied  to  the  chest,  and  opium  and  ergot. 

What  remedies  should  be  used  in  hemorrhage  from 
mucous  surfaces? 

Opium,  ergot  and  suprarenal  capsule. 

What  are  the  complications  and  sequelae  of  whooping 
cough? 

Hemorrhages  occur,  such  as  petechise,  about  the  face  and 


440  DIAGNOSIS  AND  PRACTICE. 

neck ;  epistaxis  and  hemoptysis  may  occur ;  broncho-pneumonia 
is  a  complication  which  adds  greatly  to  the  gravity  of  the 
case.  Pulmonary  tuberculosis  is  comparatively  frequent  in 
a  considerable  proportion  of  the  cases,  especially  in  adoles- 
cents.    Emphysema  is  a  frequent  sequel. 

Describe  the  treatment  of  paralysis  agitans. 

The.  treatment  is  purely  symptomatic.  Occasionally  hyos- 
cyamine  or  hyoscine  control  the  tremor.  The  general  hygiene 
of  the  patient  is  to  be  looked  after ;  tonics,  such  as  arsenic  and 
strychnia,  are  of  use.     Thyroid  extract  is  of  service. 

What  are  the  causes  of  peritonitis? 

The  most  frequent  mode  of  infection  is  through  the  intes- 
tines and  from  the  female  generative  organs.  Various  forms 
of  ulcer  may  produce  peritonitis,  such  as  the  typhoid  or  tuber- 
cular ulcer.  Malignant  disease  of  the  intestine  may  give  rise- 
to  it.  It  also  arises  from  forms  of  intestinal  obstruction,  such 
as  volvulus  and  stricture.  The  gall-bladder  and  liver  may^ 
be  the  sources  of  infection,  and  particularly  abscesses,  and 
syphilitic  disease  may  give  rise  to  it.  Obstruction  of  the 
biliary  passages  by  gall-stones  may  produce  it.  The  affection 
may  arise  from  the  spleen,  through  an  infected  embolus.  It 
may  occur  from  infective  disease  of  the  kidney,  from  disease- 
of  the  bladder  wall,  from  the  prostate  and  from  the  urethra. 
Peritonitis  occasionally  occurs  in  the  course  of  some  of  the 
acute  infectious  diseases,  such  as  erysipelas,  acute  rheumatic 
fever  and  septicemia. 

Name  the  places  where  yellow  fever  is  endemic. 

The  disease  is  endemic  in  the  West  Indies,  parts  of  the 
Mediterranean  coast  South  America  and  Africa. 

What  treatment  would  you  recommend  for  diphtheritic 
paralysis?     What  is  the  prognosis? 

Rest,  tonics,  strychnia,  and,  later,  electricity  are  useful- 
The  prognosis  in  all  forms  of  diphtheritic  paralysis  is  favor- 
able as  a  rule,  except  in  paralysis  of  the  heart. 


■■•  DIAGNOSIS  AND  PRACTICE.  441 

What  are  the  causes  and  treatment  of  acute  myelitis? 

Exposure  to  variations  of  temperature,  especially  to  cold,  is 
important.  Thus  certain  occupations  predispose,  such  as  en- 
gineers, cabmen,  drivers,  etc.  Gout,  rheumatism  and  certain 
metallic  poisons,  such  as  lead,  mercury  and  arsenic,  have  been 
recognized  as  etiologic  factors.  Alcohol  may  also  be  a  cause. 
Syphilis  usually  gives  rise  to  the  chronic  form.  Occasionally 
acute  myelitis  may  be  secondary,  resulting  from  extension,  as 
in  abscess,  caries  or  cancer  of  the  spine.  Traumatism  is  per- 
haps the  most  common  cause.  The  puerperal  period  and  the 
existence  of  septic  conditions  have  also  been  noted  as  causes  of 
the  disease.  In  the  treatment,  counter-irritation  by  blisters  or 
the  application  of  cold  are  of  use  in  the  acute  stage,  but  they 
are  contra-indicated  after  this  stage.  Precaution  should  be 
taken  not  to  interfere  with  the  nutrition  of  the  skin  on  account 
of  the  great  liability  to  trophic  changes.  Absolute  rest  is 
important.  Great  care  must  be  taken  of  the  bladder.  The 
catheter  should  be  carefully  sterilized.  Electricity  is  benefi- 
cial late  in  the  course  of  the  disease,  and  at  this  time  massage 
is  also  valuable.  A  warm  climate  favors  improvement.  Hy- 
drothearpy  has  been  highly  recommended.  General  tonics 
are  of  use ;  the  bowels  may  be  moved  by  eneraata.  In  syphi- 
litic cases  anti-syphilitic  treatment  is  indicated. 

What  are  the  complications  and  sequelae  of  scarlet 
fever? 

Diphtheria,  otitis  media  and  nephritis  are  the  most  import- 
ant complications,  and  occur  in  nearly  all  severe  cases.  En- 
docarditis occurs;  less  commonly  pericarditis.  Meningitis, 
peritonitis,  pleurisy,  with  and  without  effusion,  also  occur. 
Among  the  most  common  sequels  are  enlarged  lymphatic 
glands,  chronic  joint  affection,  the  hemorrhagic  diathesis, 
monoplegia,  hemiplegia,  peripheral  neuritis,  hysteria  and  an- 
emia. 

On  what  symptoms  would  you  base  a  diagnosis  of  ty- 
phoid fever? 

Upon  the  slow  onset,  with  a  gradual  rise  in  temperature^ 


442  DIAGNOSIS  AND  PEACTICE. 

nose-bleed,  headache,  diarrhea,  the  occurrence  on  or  about  the 
seventh  day  of  the  typical  eruption,  enlargement  of  the  spleen, 
dilated  pupils,  the  Widal  reaction,  and  the  dicrotic  pulse. 

How  should  scarlatina  be  treated? 

Strict  isolation  is  important.  The  scales  during  the  period 
of  desquamation  should  be  carefully  collected  and  burned. 
The  diet  should  be  nutritious  and  easily  assimilated.  Pure 
drinking  water  or  the  alkaline  mineral  waters  may  be  freely 
administered.  Milk  is  a  necessary  article  of  diet.  There  is 
no  specific  treatment.  A  mild  laxative  should  be  given  at  the 
onset.  Tepid  sponging,  at  least  twice  daily,  is  necessary  in 
severe  cases.  Warm  bathing  is  usually  very  grateful  to  the 
patient.  During  the  period  of  eruption  an  animal  fat.  used 
as  an  inunction  to  the  skin,  prevents  itching  and  hastens  des- 
quamation. A  mild  diuretic  maj^  be  used,  and  it  is  important 
to  keep  the  kidneys  active.  Complications  must  be  treated 
upon  general  principles. 

What  should  be  done  for  a  patient  during  the  passage  of 
a  biliary  calculus? 

Hot  fomentations  should  be  applied  over  the  lower  part  of 
the  liver.  If  the  pain  is  severe,  whiffs  of  chloroform  may  be 
inhaled.  However,  in  the  majority  of  the  cases  relief  of  the 
pain  only  follows  the  hypodermic  use  of  morphine.  If  the 
condition  is  not  relieved  by  medical  means  surgical  interfer- 
ence must  be  resorted  to. 

How  should  sniall=pox  be  treated? 

Vaccination  should  be  practiced  as  a  prophylaxis.  Com- 
plete isolation  and  disinfection  are  absolutely  necessary. 
There  is  no  specific  treatment.  Food  is  not  well  borne  at  first, 
and  there  may  be  much  vomiting  and  diarrhea.  Usually  acid 
drinks  or  small  particles  of  ice  are  grateful  to  the  patient. 
From  the  onset  of  the  disease  detergent  washes  containing 
antiseptic  solutions  should  be  used  for  the  mouth.  The  room 
should  be  darkened;  the  solar  light  being  rigidly  excluded. 
This    preventv^    pitting.      Warm    baths    two    or    three    times 


DIAGNOSIS  AND  PRACTICE.  443 

daily  are  of  decided  benefit  to  the  patient.  During  the 
time  of  secondary  fever  bold  stimulation  is  necessary.  At 
the  onset  a  laxative  is  useful.  Pain  should  be  overcome  by 
small  doses  of  opium,  but  great  care  must  be  exercised  by 
this  drug,  as  it  tends  to  lock  np  the  secretions.  Restlessness 
and  insomnia  should  be  treated  by  trional  and  sulphonal.  In 
convalescence  tonics  are  useful. 

What  is  the  treatment  for  angina  pectoris? 

For  the  attack,  hypodermics  of  morphia  are  necessary.  In- 
halations of  amyl  nitrite  or  nitroglycerin  in  full  doses  may 
prove  beneficial.  In  the  interval  between  the  attacks  the 
patient  must  lead  a  quiet  life.  The  functions  of  the  body 
should  be  well  looked  after,  and  the  administration  of  the 
nitrite  of  sodium  with  strychnine  is  of  use. 

What  should  be  done  to  give  relief  in  intestinal  obstruc= 
tion? 

The  treatment  is  largely  surgical.  Opium  should  be  given 
to  relieve  the  pain.  If  vomiting  be  persistent  the  stomach 
tube  may  be  used.  Purgatives  should  be  avoided.  Hot  tur- 
pentine stupes  may  be  applied  to  the  abdomen.  Rectal  feed- 
ing may  be  resorted  to,  but  surgical  interference  sooner  or 
later  becomes  imperative.  Atropine  in  large  doses  hypoder- 
mieally  has  been  advised. 

What  causes  cerebro=spinal  meningitis,  and  how  should 
it  be  treated? 

The  exciting  cause  is  the  diplococcus  intraceUularis  menin- 
gitidis, described  by  Weichselbaum  in  1887.  The  treatment 
is  chiefly  symptomatic.  Cold  applications  to  the  head  and  to 
the  spinal  cord  are  useful.  On  the  other  hand,  heat  to  the 
head  and  spine  may  be  preferred  by  some  patients.  A  laxa- 
tive dose  of  calomel  early  in  the  course  of  the  disease  and 
mercur>'  throughout  the  entire  affection  has  many  advocates. 
Opium  perhaps  offei-s  the  best  mode  of  treatment,  and  there 
is  a  remarkable  tolerance  for  this  drug  even  in  the  very 
young.      If   vomiting   be    a    prominent   symptom    morphine 


444  DIAGNOSIS  AND  PRACTICE. 

should  be  given  hypodermically.  Chloral,  the  bromides  and 
cannabis  indica  have  been  used,  but  in  effect  cannot  be  com- 
pared with  the  systematic  use  of  opium.  Alcohol  is  necessary 
when  depression  shows  itself  and  asthenia  is  marked.  Flex- 
ner's  serum  should  be  used. 

Describe  the  treatment  of  pericarditis. 

In  the  first  stage  ice-bags  applied  over  the  precordium  are 
of  use  in  relieving  pain  and  quieting  the  cardiac  action. 
Small  blisters  at  some  distance  from  the  precordium  are  of 
benefit,  especially  when  there  is  an  effusion.  If  pain  be 
severe  opium  in  some  form  is  necessary.  In  very  large  effu- 
sion paracentesis  is  necessary,  especially  so  if  the  effusion  be 
purulent,  in  which  condition  surgical  interference  is  impera- 
tive. Gentle  purges  from  time  to  time  are  useful.  A  mild, 
non-stimulating  diet  is  indicated. 

How  should  apoplexy  due  to  cerebral  hemorrhage  be 
treated? 

The  patient  must  be  placed  in  bed  with  the  head  elevated. 
If  arterial  tension  be  high  venesection  should  be  performed 
immediately.  Ice-bags  are  applied  to  the  head.  Croton  oil 
or  calomel  is  of  great  value  in  inducing  free  purgation.  If 
the  patient  be  unconscious  for  a  considerable  length  of  time 
the  bladder  must  be  evacuated  with  a  catheter. 

What  is  the  treatment  of  diarrhea  occuring  in  typhoid 
fever? 

Large  doses  of  bismuth,  salol  and  some  of  the  intestinal 
antiseptics  are  of  value  in  this  condition.  Opium  must  be 
administered  with  great  caution. 

Give  the  treatment  of  whooping=cough. 

Food  should  be  abundant  and  nutritious,  and  if  the  child 
vomits  during  a  paroxysm  nourishment  should  be  immediately 
readministered.  Antipyrine  in  doses  proportionate  to  the 
age  of  the  patient  has  some  influence  on  the  paroxysms, 
bromoform  is  of  use,  but  is  very  likely  to  give  rise  to  nausea. 
Good  hygiene  is  essential  in  the  treatment  of  the  case.  BeU 
ladonna  pushed  to  physiological  limits  should  be  used. 


DIAGNOSIS  AND  PRACTICE.  445 

What  measures  should  be  adopted  in  the  treatment  of 
pulmonary  edema? 

The  treatment  is  largelj^  that  of  the  primary  disease  which 
causes  the  edema.  There  should  be  active  purging,  especially 
if  cyanosis  be  absent.  Hypodermics  of  atropia  in  large  doses 
frequently  repeated  have  been  found  of  use  in  some  cases. 

How  should  endocarditis  be  treated? 

The  treatment  consists  in  absolute  rest  in  the  recumbent 
posture.  Digitalis  should  only  be  given  for  definite  and  fixed 
indications,  and  is  not  required  unle.ss  the  pulse  becomes  quick 
.and  small  or  irregular,  or  the  signs  of  failing  compensation 
occur.  Strychnia  is  of  benefit  in  this  condition.  If  anemia 
persist,  iron  with  quinine  and  arsenic  will  be  found  valuable. 
Aconite  in  small  doses  will  quiet  the  heart. 

What  measures  should  be  employed  to  rid  the  system  of 
tape=worm. 

The  most  reliable  anthelmintics  are  the  male  fern,  the  pome- 
granate root,  bark  and  its  alkaloid  pelletierin,  kousso,  pump- 
kin seed,  turpentine  and  chloroform.  Thymol  is  also  highly 
recommended  by  some  authorities.  Before  the  administration 
of  any  of  these  drugs  the  patient  should  be  put  upon  a  milk 
diet  for  at  least  twenty-four  hours.  It  is  then  desirable  the 
night  before  the  vermifuge  is  administered  to  give  a  brisk 
cathartic,  preferably  calomel.  Early  the  following  morning 
the  anthelmintic  is  administered,  and  a  few  hours  afterward 
another  purgative. 

What  are  the  ordinary  age  limits  of  typhoid  fever,  and 
what  conditions  are  essential  to  its  production? 

The  age  at  which  enteric  fever  most  frequently  occurs  is 
from  15  to  30.  The  predisposing  causes  are  temperate  cli- 
mate, autumn  months,  unfavorable  hygienic  surroundings, 
such  as  infected  drinking  water,  food,  sewage  and  poor  drain- 
age. The  exciting  cause  is  the  bacillus  of  Eberth  or  the  ba- 
-cillus  typhosus. 


446  DIAGNOSIS  AND  PRACTICE. 

How  does  the  cause  of  typhoid  fever  principally  gain 
entrance  to  the  human  body?     Outline  the  prophylaxis. 

Most  frequently  through  the  digestive  tract  in  the  form  of 
infected  drinking  water  or  milk.  The  prophylaxis  consists 
in  the  absolute  destruction  of  the  discharges  and  disinfection 
of  the  soiled  linen.  The  drinking  water  should  be  boiled,  and 
suspected  milk  should  also  be  boiled. 

Describe  the  treatment  of  cancer  of  the  stomach. 

The  most  important  point  in  the  treatment  relates  to  the 
early  diagnosis,  with  the  hope  of  operative  interference. 
Medical  methods  are  only  palliative.  They  consist  in  allevi- 
ation of  the  dyspeptic  conditions  and  the  pain.  To  accom- 
plish these  ends  systematic  lavage  and  the  use  of  opium  are 
the  most  satisfactory  agents.  Strength  may  be  maintained 
by  rectal  alimentation. 

Give  the  period  of  incubation  and  the  treatment  of 
mumps. 

The  period  of  incubation  is  about  two  weeks.  It  may  be  as 
long  as  three  weeks.  In  the  treatment  the  patient  should  be 
isolated,  and  a  mild  laxative  given  at  the  onset.  Rest  in  bed 
is  important.  Attention  should  be  given  to  the  alleviation 
of  pain. 

Describe  herpes  zoster  and  its  treatment. 

One  or  more  groups  of  small  vesicles  seated  upon  a  plane 
base  and  attended  by  neuralgic,  burning  pain,  occurring  along 
the  course  of  one 'or  more  branches  of  a  nerve,  is  known  as 
herpes  zoster.  The  process  is  acute  and  self-limited.  Mild 
cases  rarely  require  any  constitutional  treatment.  In  the 
more  severe  cases  remedies  which  invigorate  the  nervous  sys- 
tem are  of  value.  Zinc  phosphide  every  three  or  four  hours 
seems  to  be  of  service,  and  in. some  cases  quinine  and  strych- 
nine are  useful,  also  arsenic.  If  the  pain  be  very  severe 
opium  in  some  form  is  useful.  Antipyrine,  phenaeetine  and 
salicylate  of  sodium  have  been  highly  recommended.  A  dust- 
ing powder  consisting  of  oxide  of  zinc,  boric  acid  and  tale 


DIAGNOSIS  AND  FBACTWE.  4A7 

should  be  applied  over  the  vesicles.     This  may  be  changed 
daily  or  every  few  days. 

Give  the  symptoms  and  treatment  of  exophthalmic 
goitre. 

The  four  cardinal  symptoms  of  exophthalmic  goitre  are 
enlargement  of  the  thyroid  gland,  protrusion  of  the  eyeball, 
tachycardia  and  tremor.  Hydrotherapy  is  often  valuable; 
rest  in  bed  and  ice-bags  applied  to  the  precordium  give  much 
relief  to  the  patient.  Digitalis,  aconite,  veratrum,  viride, 
tincture  of  strophanthus  and  potassium  bromide  have  been 
employed  in  this  disease.  Thyroid  extract  has  also  been  lately 
recommended.  Removal  of  the  thyroid  gland  has  been  prac- 
ticed with  but  little  benefit.  Excision  of  the  cervical  sym- 
pathetic ganglia  has  relieved  some  cases. 

Name  five  diseases  caused  by  a  known  germ. 

Tuberculosis,  enteric  fever,  cholera,  plague  and  diphtheria. 
Describe  the  treatment  of  neurasthenia. 

The  study  of  the  individual  case  is  important.  The  rest 
cure  is  applicable  in  many  cases,  while  in  others  a  change  of 
climate  is  of  great  benefit.  Hydrotherapy,  electricity,  mas- 
sage and  hypnotism  have  all  been  of  value  in  the  treatment. 
The  diet  must  be  easy  of  digestion.  In  the  cerebral  variety 
the  bromides  are  valuable.  In  the  gastric  variety  ai*senic  in 
the  form  of  Fowler's  solution  is  of  service.  Syrup  of  the 
hypophosphites  and  valerian,  caffeine,  hyoscine  and  phenace- 
tine  are  of  benefit  in  suitable  cases.  Opium  and  other  hyp- 
notics must  be  used  with  great  caution.  Iron  and  cod-liver 
oil  are  useful.     Systematic  exercise  is  of  great  benefit. 

(jive  the  morbid  anatomy  and  physical  signs  of  acute 
endocarditis. 

The  lesions  are  usually  situated  in  the  left  side  of  the  heart. 
The  endocardium  lining  the  valves  is  most  frequently  affected. 
The  lesions  are  small  vegetations  varying  in  size  from  one  to 
four  niilliuiet(M-s  in  diameter.  Usually  micro-organisms  are 
associati'd  with  siinplr  ciidocardit is.     jNIicroscopically  the  first 


448  DIAGNOSIS  AND  FRACTICE. 

change  noted  in  the  endocardium  is  the  granular  degeneration 
of  the  epithelial  cells.  In  the  sub-endothelial  tissues  blood- 
vessel changes  that  accompany  inflammation  are  noted.  Co- 
agulation necrosis  and  proliferation  of  the  fixed  cells  are 
found.  The  inflammatory  exudate,  the  sub-endothelial  tissues 
and  the  fibrin  upon  the  free  surface  cause  the  bulging  or 
warty  excrescences.  Upon  this  projection,  fibrin  from  the 
blood  stream  is  also  deposited.  Intermingled  with  the  exu- 
date the  various  micro-organisms  may  be  present.  Early  on 
inspection  no  change  is  usually  noted,  and  the  important 
physical  signs  can  only  be  discovered  upon  auscultation.  As 
the  mitral  valve  is  most  frequently  involved,  a  systolic  mur- 
mur, which  has  its  maximum  intensity  at  or  near  the  apex, 
and  is  transmitted  to  the  left  axilla,  and  often  to  the  angle 
of  the  scapula,  shows  that  mitral  regurgitation  has  taken 
place.  The  murmur  is  at  first  soft  and  blowing  in  character. 
When  other  valves  are  implicated  murmurs  related  to  them 
occur.  The  pulmonic  second  sound  is  always  accented  in  this 
condition. 

Mention  the  causes  and  symptoms  of  gastralgia. 

The  condition  consists  in  severe  boring,  rumbling,  painful 
contraction  in  the  epigastric  region  extending  from  the 
xiphoid  cartilage  and  radiating  to  the  back,  accompanied  by 
syncope  and  signs  of  collapse.  The  condition  may  appear 
suddenly  without  apparent  cause,  or  may  be  due  to  slight 
pressure  in  the  epigastrium.  It  may  be  accompanied  by  the 
sensation  of  the  globus  hystericus,  bulimia,  frequent  micturi- 
tion and  vomiting.  It  disappears  after  having  lasted  a  few 
moments.  The  attacks  occur  with  marked  irregularity,  occa- 
sionally several  taking  place  in  one  day,  upon  alternate  days, 
or  not  recurring  for  months.     It  is  a  neurosis  of  the  stomach. 

Describe  the  treatment  of  leukemia. 

Rest  in  bed  is  desirable,  and  a  nutritious  diet  should  be 
given.  Arsenic  should  be  administered  early,  and  the  dose 
increased  to  the  point  of  tolerance.  This  drug  seems  to  have 
a  marked  beneficial  effect.     Ergot  has  been  recommended ; 


DIAGNOSIS  AND  PRACTICE.  449 

bone  marrow  and  iron  are  also  found  to  be  useful,  especially 
when  arsenic  is  not  well  borne.  Oxygen  inhalations  may  be 
beneficial.    X-ray  treatment  does  good  in  some  cases. 

Describe  the  symptoms  and  treatment  of  multiple 
sclerosis. 

The  first  symptoms  may  appear  after  some  mental  or  phys- 
ical strain,  the  patient  behaving  as  if  affected  by  hysteria. 
There  may  be  temporary  aphonia,  from  which  there  may  be 
speedy  recovery,  or  numbness  may  occur  in  some  part  of  the 
body.  These  symptoms  may  disappear  for  a  time  and  re- 
appear with  increased  severity.  Charcot  has  given  the  fol- 
lowing description :  The  patient  develops  spastic  paraplegia 
with  exaggerated  reflexes,  with  ankle  clonus  and  limited 
movements.  An  irregular  .jerk^-  tension  tremor  occurs,  nys- 
tagmus being  a  prominent  symptom.  Diplopia  and  paralysis 
of  the  ocular  muscle  are  common.  Scanning  speech  is  prom- 
inent. There  are  parathesia.  tinnitus  aurium  and  vertigo. 
The  mental  faculties  are  blunted,  and  in  some  few  cases  apo- 
plectiform and  epileptiform  convulsions  occur.  Trophic 
changes  arise  late  in  the  disease,  the  sphincters,  however, 
remaining  normal.  The  treatment  is  the  same  as  in  other 
forms  of  sclerosis.  The  salts  of  gold,  silver  and  arsenic  have 
been  recommended. 

Describe  the  eruptions  in  the  eruptive  fevers.  State 
where  they  first  appear  and  the  time  of  their  appearance. 

In  scarlet  fever  the  eruption  occurs  at  the  end  of  the  first 
day  or  beginning  of  the  second  day.  It  consists  of  pin-head 
points  appearing  first  upon  the  neck  and  chest  and  spreading 
rapidly  all  over  the  body,  except  certain  parts  of  the  face,  the 
mouth  and  chin.  These  red  points,  which  are  close  together, 
soon  coalesce,  giving  a  diffuse  pinkish  or  reddi.sh  appearance 
to  the  entire  skin,  which  presents  a  boiled  lobster  color.  Some 
slight  edema  may  also  be  noted.  Throughout  the  entire  erup- 
tion raised  papules  are  found.  The  eruption  lasts  about  four 
or  five  days,  and  disappears  by  desquamation. 

The  eruption  in  measles  occurs  upon  the  fourth  day.  It 
29 


450  DIAGNOSIS  AND  PRACTICE. 

appears  first  upon  the  face  and  neck,  and  spreads  rapidly 
over  the  entire  body.  The  eruption  consists  of  rose-red  or 
brownish  maculo-papular  points  raised  above  the  skin,  with 
intervening  healthy  skin,  often  arranged  in  a  erescentic  shape, 
especially  upon  the  forehead  and  wrists.  The  eruption  re- 
mains at  its  height  for  about  four  days. 

The  eruption  in  rubella  appears  upon  the  first  day,  and 
occurs  irregularly  over  the  face,  neck,  chest,  body  and  limbs, 
varying  in  individual  cases  and  in  different  epidemics.  The 
multiform  eruption  may  resemble  erythema,  urticaria,  and 
in  some  cases  that  of  true  measles  or  scarlet  fever.  It  may 
be  confluent  or  diffuse,  lasting  from  two  to  four  days. 

The  eruption  in  small-pox  occurs  upon  the  third  day.  The 
temperature  falls  as  the  eruption  occurs.  The  eruption  may 
be  discrete  or  confluent.  At  first  the  rash  is  about  the  size 
of  a  pin-head,  and  soon  becomes  hard,  feeling  like  a  shot 
under  the  skin.  The  macular  eruption  is  rapidly  converted 
into  a  papule  of  a  reddish  color.  There  may  be  itching  and 
burning  attending  these  early  eruptive  symptoms.  In  from 
twenty-four  to  forty-eight  hours  the  rash  has  invaded  the  en- 
tire body,  the  earlier  papules  soon  become  vesicular,  this 
change  taking  place  about  the  sixth  or  seventh  day  from 
the  onset  of  the  attack.  In  a  day  or  so  the  fluid  becomes 
turbid  and  purulent,  the  top  being  held  down  (primary  um- 
bilication) .  In  from  twenty-four  to  forty-eight  hours  this 
umbilication  has  disappeared,  the  top  now  being  conic  in 
shape.  About  this  time  an  intense  red  inflammatory  areola 
is  noticed  about  the  base  of  the  pock,  and  the  eruption  is  now 
exceedingly  painful.  On  or  about  the  ninth  day  from  the 
beginning  of  the  disease  suppuration  begins  in  the  pock,  last- 
ing about  three  days,  when  the  apex  of  the  cone  drops  in,  due 
to  the  absorption  of  the  contents  of  the  pock  (secondary  um- 
bilication). "When  absorption  has  been  completed  a  crust 
forms  that  may  remain  for  some  days,  these  crusts  falling  off 
on  or  about  the  sixteenth  day  from  the  beginning  of  the  dis- 
ease, leaving  depressed  striated  scars. 

The  eruption  in  varicella  occurs  upon  the  first  day,  and 


DIAGNOSIS  AND  PRACTICE.  451 

marks  the  beginning  of  the  disease.  The  exanthem  shows 
itself  as  a  small  reddish  point  or  papule,  which  in  a  very  few 
hours  becomes  a  vesicle.  It  is  slightly  elevated  above  the 
skin  rather  than  having  the  appearance  of  being  under  the 
skin;  the  vesicles  are  thin  and  transparent,  and  from  one- 
eighth  to  one-quarter  of  an  inch  in  diameter.  There  is  usually 
no  areola.  In  the  course  of  a  few  hours  the  vesicle  becomes 
milky  and  begins  to  shrivel,  with  depression  at  the  top  from 
absorption  of  its  contents.  This  results  as  a  yellowish-brown 
crust  that  in  about  ten  days  from  the  beginning  of  the  at- 
tack, and  even  before  this,  separates,  leaving  a  more  or  less 
well-defined  sear,  which  in  some  cases,  especially  upon  the 
face,  remains  permanently.  The  pocks  may  appear  upon  the 
face,  neck,  scalp,  wrist  and  some  parts  of  the  body. 

Give  the  symptoms  of  acute  pericarditis. 

It  is  impossible  to  diagnosticate  a  true  pericarditis  by 
symptoms  without  a  careful  physical  examination.  The  dis- 
ease commonly  begins  with  severe  pain  in  the  region  of  the 
precordium.  The  pulse  rate  increases,  and  may  be  from  90 
to  160  per  minute.  In  some  cases  it  may  be  normal,  or  when 
effusion  occurs  the  pulsus  paradoxus  occurs.  Fever  of  some 
degree  is  usually  present.  The  most  important  sign  is  a  fric- 
tion sound,  which  varies  greatly  in  intensity.  It  is  limited 
to  the  precordial  area,  and  is  heard  most  frequently  at  the 
base  of  the  heart.  It  is  increased  by  pressure  with  the  stetho- 
scope. If  an  effusion  develops,  the  friction  sound  disappears, 
and  returns  again  as  absorption  takes  place. 

What  are  the  complications  and  sequelae  of  cerebro- 
spinal fever? 

The  important  complications  are  broncho-pneumonia,  bron- 
chitis, croupous  pneumonia,  endocarditis  and  pericarditis. 
The  sequels  are  exceedingly  common.  They  consist  in  affec- 
tions of  the  special  senses.  There  may  be  loss  of  sight,  per- 
manent deafness,  loss  of  smell,  loss  of  taste,  various  forms  of 
paralysis,  neuralgia,  and  mental  impairment. 


452  DIAGNOSIS  AND  PRACTICE. 

Describe  the  eruption  of  typhus  fever. 

The  characteristic  eruption  of  typhus  appears  upon  the 
fifth  day  of  the  disease,  and  in  its  early  stages  closely  resem- 
bles measles.  Macular  spots  of  irregular  size  and  outline, 
and  of  a  dirty  pinkish  or  reddish  color,  characterize  the  ex- 
anthem.  It  appears  first  upon  the  chest  and  abdomen,  and 
extends  to  the  extremities,  the  face  being  rarely  affected.  It 
is  particularly  copious  upon  the  extremities,  where  later  in 
the  disease  it  becomes  darker  or  petechial.  Another  erup- 
tion is  also  characteristic,  and  consists  of  marbling  or  mottling 
of  the  skin.  This  rash  lasts  throughout  the  disease,  and  does 
not  disappear  in  death. 

Describe  the  treatment  of  measles. 

There  is  no  specific  treatment,  and  in  uncomplicated  cases 
medicines  are  unnecessary.  A  mild  laxative  at  the  onset  is 
useful.  The  entire  treatment  should  be  directed  to  the  pre- 
vention of  complications,  especially  broncho-pneumonia. 
When  complications  occur  they  must  be  treated  upon  general 
principles.  Rest  in  bed  until  the  bronchitis  and  the  rash  have 
lessened  is  necessary. 

Give  the  physical  signs  of  a  cavity  of  the  lung  in  pul= 
monary  tuberculosis. 

If  the  cavity  be  large  and  superficially  situated  there  will 
be  depression  upon  inspection.  Upon  palpation,  if  the  cavity 
be  empty,  there  will  be  increased  vocal  fremitus.  Upon  per- 
cussion, if  the  cavity  is  empty,  a  tympanitic  note  may  be  elic- 
ited. If  the  cavity  communicate  with  the  bronchus  a  cracked- 
pot  sound  may  occur.  If  the  cavity  be  filled  dulness  will  be 
noted  upon  percussion.  On  auscultation,  if  the  cavity  be 
empty,  increased  vocal  resonance  and  cavernous  breathing 
will  be  heard.  If  fluid  be  present  in  the  cavity  bubbling  rales 
are  heard.  Around  the  cavity  a  friction  sound  is  frequently 
noted. 

Give  the  etiology  and  treatment  of  hemothorax. 

Hemothorax  may  result  from  traumatism,  caused  by  frac- 


DIAGNOSIS  AND  PRACTICE.  453 

ture  of  a  rib  or  wounding  of  a  lung.  It  may  also  result  from 
rupture  of  an  aneurysm,  from  malignant  disease  of  the  lung, 
and  in  the  hemorrhagic  diathesis.  If  the  hemothorax  be  mod- 
erate in  size  it  should  not  be  interfered  with,  as  subsequent 
absorption  and  clotting  will  take  place.  Rest  and  the  free 
administration  of  opium  are  necessary.  Avoid  stimulation, 
for  it  will  interfere  with  the  formation  of  a  clot. 

Describe  the  characteristics  and  significance  of  the 
several  kinds  of  arterial  pulse. 

The  normal  radial  pulse  is  characterized  by  regularity,  fair 
volume,  and,  in  the  healthy  adult,  is  from  70  to  80  per  minute 
in  the  erect  posture.  The  pulse  of  aortic  regurgitation  is 
known  as  the  water-hammer  or  Corrigan's  pulse.  It  makes 
itself  known  by  an  apparent  fulness,  which,  however,  soon 
passes,  and  it  recedes  from  the  finger,  hence  it  is  also  known 
as  the  receding  pulse.  The  pulse  of  mitral  stenosis  is  a  small, 
irregular,  rapid  pulse.  The  dicrotic  pulse  conveys  to  the 
finger  a  double  beat. 

Diagnosticate  diabetes  mellitus. 

The  diagnosis  of  diabetes  mellitus  consists  in  the  continuous 
presence  of  glucose  in  the  urine.  The  amount  of  urine  passed 
by  the  patient  may  be  from  3  to  5  quarts  in  the  24  hours ;  its 
specific  gravity  is  usually  high,  1030  or  over.  The  color  is 
usually  straw-colored,  and  the  urine  is  clear.  The  patient  has 
great  thirst,  large  appetite,  as  a  rule  loses  weight,  and  an 
etherial  odor  may  often  be  detected  in  the  breath;  there  is 
pruritus,  especially  of  the  genitals,  and  boils  and  carbuncles 
are  apt  to  form. 

Differentiate  gastric  cancer  from  gastric  ulcer. 

Gastric  cancer  occurs  after  the  age  of  40,  most  frequently 
in  the  male  sex;  gastric  ulcer  is  a  disease  most  frequently 
oecuring  in  young  females  in  whom  chlorosis  is  often  present. 
Gastric  cancer  is  characterized  by  loss  of  weight,  marked 
cachexia,  and  often  by  the  presence  of  a  tumor  in  the  region 
of  the  pylorus.    There  is  pain  which,  as  a  rule,  is  dull  in  char- 


454  DIAGNOSIS  AND  PRACTICE. 

acter  and  not  particularly  aggravated  by  food.  Vomiting 
occurs  after  a  longer  period,  24  hours  or  more,  of  food  which 
is  but  partially  digested.  The  Oppler-Boas  bacillus  may  be 
present  in  the  vomited  material,  and  there  may  also  be  tinges 
of  blood.  In  ulcer  there  is  pain  and  marked  tenderness  in 
the  region  of  the  ensiform  cartilage.  This  pain  is  greatly 
aggravated  by  the  taking  of  food ;  vomiting  occurs  soon  after 
a  meal;  there  is  frequently  hematemesis.  In  the  examination 
of  the  gastric  contents  it  will  be  found  that  in  cancer  there  is 
an  absence  of  free  HCl  and  the  presence  of  lactic  acid,  while 
in  ulcer  there  is  an  excess  of  free  HCl. 

Differentiate  scarlatina,  measles  and  roseola. 

In  scarlatina  the  eruption  appears  late  on  the  first  day  or 
early  on  the  second  day  of  the  disease,  while  in  measles  it 
appears  on  the  fourth  day,  and  in  roseola  the  eruption  is  the 
first  symptom  of  the  disease.  The  onset  in  scarlet  fever  is 
abrupt,  with  a  chill  or  convulsion,  high  temperature,  rapid 
pulse,  140-160  per  minute  or  more,  sore  throat,  etc.  In 
measles  the  onset  is  characterized  by  marked  catarrhal  symp- 
toms, such  as  sneezing,  coughing,  lachrymation,  etc. ;  the  tem- 
perature moderate,  there  is  slight  sore  throat  and  mild  gastric 
disturbance. 

How  would  you  diagnose  pneumonia? 

The  direct  diagnosis  of  pneumonia  depends  upon  the  sudden 
onset  with  chill,  temperature  which,  as  a  rule,  is  high,  severe 
pain  in  the  side,  cough,  at  first  with  scanty  expectoration,  later 
the  expectoration  becoming  very  tenacious  and  containing 
blood  (rusty  sputum),  and  upon  the  physical  signs.  These 
consist  of  the  crepitant  rale  in  the  first  stage,  dulness  on  per- 
cussion in  the  second  stage  with  bronchial  breathing,  and  the 
occurrence  of  the  crepitus  redux  in  the  third  stage. 

Differentiate  peritonitis  and  enteritis. 

In  peritonitis  there  are  present  marked  abdominal  pain, 
tenderness  on  pressure,  abdominal  distension,  after  which 
effusion  is  apt  to  occur,  vomiting,  which  becomes  persistent, 


DIAGNOSIS  AND  PRACTICE.  455 

fever  and  perhaps  the  occurrence  of  collapse;  marked  consti- 
pation is  an  important  symptom.  In  enteritis  there  is  diar- 
rhea, there  is  rarely  marked  distension,  no  abdominal  rigidity ; 
as  a  rule,  there  is  the  history  of  some  dietetic  error. 

Differentiate  organic  and  functional  heart  murmur. 

Organic  murmurs  may  be  systolic,  presystolic  or  diastolic  in 
time.  There  is  evidence  of  either  cardiac  hypertrophy  or 
dilatation  or  both.  The  murmur  is  conducted  in  certain  de- 
finite directions  (except  the  presystolic  murmur).  A  thrill  is 
sometimes  present.  A  functional  murmur  is  always  systolic 
in  time ;  it  is  heard  at  the  base,  particularly  at  the  left  base 
(whereas  the  organic  murmur  is  heard  at  the  punctum  maxi- 
mum), it  is  not  transmitted,  there  is  no  evidence  of  hyper- 
trophy or  dilatation,  and  it  is  present  in  anemic  conditions. 

Describe  three  pathological  pulmonary  sounds  heard  on 
auscultation,  and  give  their  significance  in  diagnosis. 

The  friction  sound  which  may  be  heard  in  inspiration,  expi- 
ration or  both,  which  indicates  a  fibrinous  pleurisy.  A  crep- 
itant rale,  which  usually  indicates  fluid  in  the  vesicular  struc- 
ture of  the  lung.     Amphoric  breathing,  showing  a  cavity. 

Differentiate  aortic  stenosis  and  aortic  insufficiency. 

In  aortic  stenosis  the  murmur  is  systolic  in  time,  transmitted 
to  the  arteries  of  the  neck ;  a  systolic  thrill  is  also  often  pres- 
ent, there  is  some  evidence  of  hypertrophy  of  the  left  ventri- 
cle, the  pulse  is  small  and,  as  a  rule,  not  rapid.  In  aortic 
regurgitation  the  murmur  is  diastolic  in  time,  heard  at  the 
right  base,  conducted  down  the  sternum.  The  water-hammer 
or  Corrigan  pulse  is  present.  There  is  marked  evidence  of 
hypertrophy  of  the  left  ventricle.  Occasionally  the  "  Flint 
murmur  "  may  be  heard. 

Differentiate  typhoid  fever  and  remittent  fever. 

In  typhoid  fever  prodromes  are  present,  such  as  loss  of 
appetite,  headache,  diarrhea,  evening  fever,  becoming  more 
marked  each  succeeding  night.  On  or  about  the  7th  day  the 
characteristic  eruption  appears,  the  typical  tongue  makes  its 


456  DIAGNOSIS  AND  PRACTICE. 

appearance,  the  spleen  is  enlarged,  and  the  dici'otic  pulse  is 
found  during  the  second  week.  The  Widal  and  diazo  reac- 
tions are  present.  Remittent  fever  may  be  present  in  many 
of  these  cases;  there  is,  however,  no  Widal  or  diazo  reac- 
tion, no  dicrotic  pulse,  and  the  presence  in  the  blood  of  the 
Plasmodium  malarias  will  in  all  cases  lead  to  a  correct  diag- 
nosis. 

Describe  four  peculiar  appearances  of  the  tongue  and 
give  their  significance  in  diagnosis. 

A  flabby,  indented,  swollen  tongue,  covered  with  a  yellowish 
fur  shows  catarrhal  gastritis.  This  tongue  is  also  seen  in 
smokere  and  drinkers,  and  occurs  often  in  moderate  fevers. 
A  tongue  which  is  red  at  the  edges  and  tips  and  is  coated  pos- 
teriorly occurs  in  enteric  fever.  The  "  strawberry  "  or  cat 
tongue,  in  which  the  papilla  are  elevated  and  a  slight  grayish 
fur  is  seen,  occurs  in  scarlet  fever.  Furrings  which  are  small 
and  limited  indicate  irritation  from  a  rough  tooth  or  inflam- 
mation of  a  tonsil. 

Differentiate  acute  rheumatism  and  periostitis. 

Acute  rheumatism  is  characterized  by  redness,  swelling  and 
pain  in  the  joints,  by  fever  of  a  moderate  range,  by  acid 
sweats  and  constant  tendency  to  inflammation  of  the  serous 
membranes  of  the  heart.  Periostitis,  as  a  rule,  follows  an 
injury;  the  pain  is  more  localized  and  does  not  refer  to  the 
joints ;  there  are  no  acid  sweats,  and  pus  formation  may  occur, 
which  is  exceedingly  rare  in  acute  rheumatism. 

Differentiate  neuritis  from  myalgia. 

In  neuritis  the  pain  is,  as  a  rule,  along  the  nerve  trunks; 
trophic  changes  may  occur.  In  myalgia  pain  is  over  the  mus- 
cles; there  is  no  constitutional  disturbance;  fever  is  entirely 
absent;  pressure  upon  the  affected  area  in  myalgia  gives  re- 
lief; in  neuralgia  the  pain  is  aggravated  by  pressure. 

Describe  the  symptoms  of  yellow  fever. 

For  convenience  of  description  the  disease  is  divided  into 
three  stages:  The  stage  of  onset,  which  generally  lasts  three 


DIAGNOSIS  AND  PRACTICE.  457 

days ;  the  period  of  calm,  which  lasts  from  12  to  24  houi-s ;  and 
the  period  of  collapse,  the  duration  of  which  is  indefinite.  In 
the  first  stage  there  is  headache,  pain  in  the  bones,  nausea  and 
vomiting,  moderate  fever,  the  pulse  may  be  80  to  100  in  a  min- 
ute, and  becomes  progressively  slower  as  the  disease  advances, 
the  urine  is  albuminous;  there  may  be  even  in  this  stage  slight 
jaundice.  These  symptoms  disappear  more  or  less  abruptly 
and  give  place  to  the  stage  of  calm,  in  which  all  the  previous 
symptoms  disappear ;  and  recovery  from  this  stage  may  be 
uninterrupted.  If  this  favorable  event  should  not  occur,  the 
third  stage  is  ushered  in,  with  the  appearance  of  marked  jaun- 
dice, from  which  the  disease  receives  its  name.  There  may  be 
hemorrhage  from  any  of  the  internal  organs,  most  frequently, 
however,  from  the  stomach,  the  characteristic  black  vomit. 
The  symptoms  of  the  first  stage  are  added  to  this. 

Give  the  diagnosis  of  gastric  ulcer. 

The  disease  is  most  frequent  in  young  anemic  females. 
There  is  pain  and  tenderness  on  pressure  in  the  region  of  the 
ensiform  cartilage ;  there  is  vomiting  and  hematemesis  and  ob- 
stinate constipation.  Examination  of  the  gastric  contents 
shows  an  excess  of  HCl.  General  nervous  symptoms  are 
prominent. 

Give  the  symptoms  resulting  from  paralysis  of  the 
phrenic  nerve. 

This  is  a  paralysis  of  the  diaphragm,  if  the  condition  is  bi- 
lateral; no  movement  is  noted  on  the  abdomen  and  epigas- 
trium; the  hypochondrium  is  drawn  in;  marked  dy.spnea  oc- 
curs upon  the  slightest  exertion.  There  may  be  enlargement 
of  the  chest. 

What  is  the  significance  of  the  patellar  reflex  as  a  sign 
of  disease? 

Absence  of  the  knee-jerk  is  caused  by  a  lesion  affecting  any 
region  of  the  reflex  arc;  it  is,  therefore,  lost  in  disease  affect- 
ing either  motor  or  sensory  fibers  or  both,  as  in  neuritis,  in 
disease  of  the  posterior  roots  or  columns,  as  in  Friedreich's 


458  DIAGNOSIS  AND  PRACTICE. 

ataxia.  It  may  be  absent  in  apoplexy,  epilepsy,  injury  to  the 
cord  or  in  meningitis;  it  is  sometimes  absent  in  diabetes, 
diphtheria  and  chorea.  It  is  exaggerated  in  hemiplegia  fol- 
lo'\\dng  apoplexy,  in  the  cerebral  palsies  of  children,  in  general 
paralysis  of  the  insane,  also  in  hysteria,  neurasthenia  and 
strychnine  poisoning. 

Differentiate  epilepsy  from  hysteria. 

Epilepsy  is  often  preceded  by  an  aura,  followed  by  complete 
loss  of  consciousness.  There  are  at  first  tonic,  followed  by 
clonic,  convulsions;  during  the  attack  the  pupils  are  dilated; 
the  patients  often  bite  their  tongues.  In  hysteria  there  is 
never  complete  loss  of  consciousness;  there  is  no  regularity 
with  regard  to  the  convulsion ;  it  is  most  common  in  females 
between  the  ages  of  15  and  25 ;  the  pupils  are  irregular,  hys- 
terogenic zones  are  present,  the  patient  never  falls  so  that  she 
may  be  injured. 

Differentiate  neuritis  and  rheumatism. 

In  neuritis  the  pain  is  commonly  along  the  nerve  trunks; 
trophic  changes  occur ;  there  may  be  foot-drop  or  wrist-drop ; 
fever  is  slight.  In  rheumatism  there  is  redness,  swelling  and 
pain  in  the  joints,  acid  sweats,  frequent  implication  of  the 
membranes  of  the  heart,  marked  deposits  of  urates  in  the 
urine. 

Differentiate  acute  phthisis  and  capillary  bronchitis. 

There  is  a  form  of  acute  pulmonary  phthisis  which  is  known 
as  the  broncho-pneumonic  form,  which  can  with  the  greatest 
difficulty  only  be  differentiated  from  so-called  capillary  bron- 
chitis. The  main  points  of  difference  would  consist  in  the 
progressive  emaciation,  a  family  history  of  tuberculosis,  the 
finding  of  tubercle  bacilli  in  the  sputum,  and  the  appearance 
of  the  physical  signs  in  the  lungs. 

What  are  the  clinical  manifestations  of  biliary  calculi? 

As  long  as  the  calculi  remain  quiescent  in  the  gall-bladder 
no  symptoms  arise.  It  is  only  upon  the  passage  of  the  gall- 
stones into  the  duct  that  the  symptoms  of  hepatic  colic  arise^ 


DIAGNOSIS  AND  PRACTICE.  459 

which  consist  in  great  pain  in  the  region  of  the  liver,  radiating 
toward  the  umbilicus  and  right  shoulder-blade,  nausea  and 
vomiting  and,  after  the  passage  of  stones,  jaundice,  clay- 
colored  stools  and  the  appearance  of  biliary  pigments  in  the 
urine. 

Differentiate  empyema  from  pulmonary  abscess. 

In  pulmonarj'  abscess  there  is  a  fever  of  a  septic  type,  the 
physical  signs  of  a  cavity  are  commonly  present,  frequently 
expectoration  of  foul-smelling  pus,  which  under  the  micro- 
scope shows  elastic  fibers.  In  such  cases  leukocytosis  is  pres- 
ent. In  empyema  there  are  the  usual  signs  of  pleural  effusion, 
the  temperature  may  range  from  102°  to  105°,  displacement  of 
the  heart  and  the  adjacent  organs  is  common,  local  edema 
and  redness  of  the  skin  are  often  present. 

Describe  the  diagnostic  characteristics  of  the  eruption 
of  typhoid  fever,  smallpox  and  chicken=pox. 

The  eruption  of  typhoid  fever  appears  about  the  seventh 
day,  consisting  of  slightly  elevated,  rose-colored  spots,  which 
disappear  on  pressure  and  appear  again  after  the  pressure  is 
removed ;  they  occur  in  crops,  having  a  duration  of  from  two 
to  three  days ;  they  appear  commonly  on  the  abdomen,  chest, 
between  the  shoulder-blades,  extremely  rarely  upon  the  face. 
The  eruption  of  smallpox  appears  on  the  third  day  in  the 
form  of  a  macula,  passing  through  the  successive  stages  of 
vesicle,  pustule,  crust  and  scar.  The  pustule  is  umbilicated 
and  has  an  inflammatory  areola;  the  eruption  appears  all  ovei- 
the  body,  especially  on  the  exposed  parts.  The  eruption  of 
chicken-pox  appears  on  the  first  day;  it  appears  as  a  small 
reddish  papule,  which  in  a  very  few  hours  becomes  a  vesicle; 
the  vesicle  is  thin  and  transparent. 

Differentiate  diphtheria  from  follicular  tonsillitis. 

In  diphtheria  the  exudate  is  found  upon  all  parts  of  the 
posterior  pharynx,  uvula  and  tonsils.  Around  the  exudate 
there  is  an  inflamed  areola.  The  exudate  is  removed  with 
great  difficulty,  leaving  a  bleeding  surface,   the   false  mem- 


460  DIAGNOSIS  AND  PBACTICE. 

brane  rapidly  reforming.  In  follicular  tonsillitis  the  exudate 
is  strictly  limited  to  the  crypts  of  the  tonsils ;  it  is  wiped  away 
with  ease,  without  leaving  a  bleeding  surface,  and  it  does  not 
reform.  The  Klebs-Lofifler  bacillus  is  found  only  in  the  diph- 
theritic exudate. 

Differentiate  acute  enteritis  from  acute  dysentery. 

In  dysentery  the  important  symptoms  to  be  considered  are 
tormina,  tenesmus  and  stools  composed  of  mucus  and  blood. 
These  symptoms  in  acute  enteritis  do  not  occur  in  anything 
like  the  severity  and  constancy  that  they  do  in  dysentery. 

Differentiate  appendicitis  from  enteric  fever. 

As  a  rule,  appendicitis  begins  abruptly,  with  marked  pain 
in  the  right  iliac  fossa  over  McBurney's  point.  There  is  con- 
stipation, tenderness,  board-like  rigidity,  all  this  occurring, 
as  a  rule,  within  a  few  days.  The  onset  of  enteric  fever  is 
gradual,  with  prodromes  of  diarrhea,  headache,  characteristic 
tongue,  appearance  of  the  eruption  about  the  seventh  day, 
enlargement  of  the  spleen,  dicrotic  pulse,  Widal  reaction. 

Differentiate  acute  pericarditis  from  acute  endocarditis. 

In  pericarditis  there  is  pain  in  the  precordium.  This,  as 
a  rule,  is  absent  in  endocarditis.  In  pericarditis  there  is  a 
friction  sound,  which  may  be  either  systolic  or  diastolic,  but 
as  a  rule,  is  not  related  to  either.  In  endocarditis  there  is  a 
murmur,  which  is  either  systolic,  dias"tolic  or  presystolic;  the 
murmur  is  transmitted,  the  friction  sound  is  localized.  The 
murmur  is  heard  at  the  punctum  maximum ;  the  friction  sound 
is  heard  over  the  body  of  the  heart  and  is  nearer  the  ear. 

How  would  you  diagnose  a  case  of  rickets? 

Sometime  between  the  seventh  month  and  second  year  of 
life  the  patient  shows  irritability,  restlessness  and  some  fever 
toward  evening,  dentition  is  delayed  and  gastro-intestinal 
disturbances  follow ;  there  is  profuse  sweating.  The  shape 
of  the  head  is  characteristic;  it  is  rectangular,  the  face  ap- 
pearing small   in   proportion   to   the  skull,  bone  changes  are 


DIAGNOSIS  AND  PRACTICE.  461 

noted,  particularly  of  the  long  bones  with  enlargement  of 
articular  surfaces,  and  the  rachitic  rosary  appears. 

Differentiate  variola  and  varicella. 

In  variola  the  eruption  appears  on  the  third  day,  preceded 
by  marked  constitutional  symptoms.  The  eruption  goes 
through  the  successive  stages  of  macule,  papule,  vesicle,  pus- 
tule, which  is  umbilicated  and  surrounded  by  an  inflammatory 
areola,  crust  and  scar.  The  eruption  in  varicella  appears  on 
the  first  day  and  is  vesicular  almost  from  the  beginning. 
There  are  rarely  marked  constitutional  phenomena,  and  the 
disease  is  essentially  one  of  childhood. 

Differentiate  apoplexy  from  uremic  coma. 

This  is  often  very  difficult;  however,  the  following  points 
favor  apoplexy:  Profound  coma,  the  face  may  be  pale  and 
cyanotic  or  flushed ;  respiration  is  stertorous  and  slow  and 
may  be  of  the  Cheyne-Stokes  type ;  hard  arteries,  with  a  slow, 
hard,  irregular,  full  pulse ;  the  pupils  are  dilated  or  unequal 
and  do  not  react  to  light ;  conjugate  deviation  of  the  head  may 
be  present ;  there  is  evidence  of  paralysis ;  the  skin  is  hot  and 
dry.  The  coma  in  uremia  may  be  preceded  by,  or  accompanied 
with,  convulsions;  the  face  may  be  pale  and  edematous;  the 
pulse  is  slow  and  of  high  tension,  showing  either  hypertrophy 
of  the  heart  or  sclerosis  of  the  vessels ;  there  may  be  a  urinous 
odor  exhaling  from  the  patient;  frequently  there  is  edema  of 
the  feet;  albumin -and  casts  are  found  in  the  urine;  albumi- 
nuric retinitis  may  be  present. 

Differentiate  unconsciousness  from  apoplexy,  syncope 
and  alcoholic  intoxication. 

(Apoplexy,  see  above).  In  syncope  the  face  is  very  pallid, 
the  pulse  is  very  weak,  and  the  pupils  are  markedly  dilated. 
In  alcoholic  coma  the  unconsciousness  is  rarely  complete.  The 
alcoholic  odor  of  the  breath  is  not  diagnostic,  as  apoplexy  and 
uremia  may  occur  in  persons  that  have  been  drinking.  The 
pulse  is  at  first  rapid  and  full,  later  becoming  small  and  fee- 
ble. The  pupils  are  equal  and  often  dilated.  The  skin  is 
cool  and  moist  and  the  temperature  subnormal. 


462  DIAGNOSIS  AND  PRACTICE. 

Differentiate  cardiac  hypertrophy  from  cardiac  dilata^ 
tion. 

In  cardiac  hypertrophy  the  apex-beat  is  displaced  down- 
ward and  to  the  left.  The  first  sound  of  the  heart  is  strong 
and  booming.  The  pulse  is  slow  and  strong.  In  cardiac  dila- 
tation the  apex-beat  is  displaced  to  the  right.  It  is  diffused 
and  feeble,  the  first  sound  being  weak.  The  pulse  is  often 
rapid,  irregular  and  weak. 

Differentiate  Asiatic  cholera  from  cholera  morbus. 

This  often  presents  great  difficulties,  especially  in  times  of 
an  epidemic  of  cholera;  however,  the  finding  of  the  comma 
bacillus  will  in  all  cases  clear  up  the  diagnosis.  Rice  water 
discharges  are  much  more  common  in  true  cholera.  In  cholera 
morbus  there  is  usually  the  history  of  an  indiscretion  in  diet. 

Differentiate  heat  exhaustion  from  sunstroke. 

In  heat  exhaustion  premonitory  symptoms  occur,  such  as 
dizziness,  headache,  nausea  and  vomiting.  The  respirations 
are  increased  in  number,  and  the  pulse  is  very  rapid,  130-140 
per  minute.  Unconsciousness  is  not  profound.  The  temper- 
ature may  be  normal  or  subnormal,  or  slight  fever  may  be 
present.  In  sunstroke  there  may  or  may  not  be  prodromes. 
The  temperature  is  very  high,  from  106°-115°,  or  even  higher. 
Dyspnea  is  marked,  and  the  skin  of  the  body  is  red  and  some- 
times even  livid.  The  pupils  are  contracted  and  the  pulse  is 
very  rapid.  There  is  complete  unconsciousness  in  which  con- 
vulsions may  occur.    Cheyne-Stokes  breathing  may  be  present. 

Diagnosticate  parenchymatous  nephritis. 

The  face  is  pale  and  edematous.  The  pulse  is  full  and 
strong,  showing  some  hypertrophy  of  the  heart  at  first,  al- 
though this  is  not  nearly  as  common  as  in  the  interstitial 
variety.  The  urine  is  decreased  in  amount,  of  high  specific 
gravity,  high-colored,  and  contains  large  amounts  of  albumin 
and  casts.     Often  there  is  also  edema  of  the  lower  extremity. 

Differentiate  aortic  and  mitral  valvular  diseases. 

In  aortic  diseases  the  murmur  is  heard  with  the  greatest  in- 


DIAGNOSIS  ANV  PRACTICE.  463 

tensity  at  the  aortic  cartilage  (second  right  costal  cartilage)  ; 
it  is  either  transmitted  to  the  neck,  if  it  be  systolic,  or  it  is 
transmitted  down  the  sternum,  if  the  murmurs  be  diastolic  in 
time.  In  aortic  valvular  disease  there  is  always  hypertrophy 
of  the  left  ventricle.  In  mitral  disease  the  murmur  is  heard 
at  the  apex.  It  is  transmitted  to  the  axilla  and  the  angle  of 
the  scapula  if  the  murmur  be  systolic  in  time.  The  presys- 
tolic murmur  is  not  transmitted  and  is  accompanied  with  a 
presystolic  thrill.  The  right  ventricle  is  constantly  hyper- 
trophied  in  mitral  disease. 

When  is  perforation  in  typhoid  fever  most  likely  to 
occur? 

Sometimes  in  the  course  of  the  third  week. 

Describe  the  essentially  different  sounds  given  by  the 
thorax  on  percussion. 

Tympany  is  elicited  over  the  trachea,  resonance  over  the 
lungs,  dulness  ovei*  the  heart. 

In  what  cases  would  the  ophthalmoscope  aid  in  d\ag= 
nosis? 

In  diseases  of  the  arteries  (retinal  hemorrhages).  In  dis- 
ease of  the  kidney,  in  disease  of  the  nervous  system,  syphilis, 
tobacco-poisoning,  lead-poisoning,  tubercular  meningitis,  dia- 
betes, brain  tumor,  etc. 

Differentiate  in  a  general  way  between  cerebrospinal 
fever  and  tubercular  meningitis. 

The  onset  of  tuberculosis  is  not  so  sudden  as  in  cerebro- 
spinal meningitis;  the  pains,  hyperesthesia  and  retraction  are 
less,  and  there  are  no  eruptions.  Retraction  of  the  abdomen, 
irregular  pulse  and  Cheyne-Stokes  respiration  are  much  more 
frequent.  A  pre-existing  tuberculous  lesion  may  be  found, 
and  the  ophthalmoscope  may  reveal  tubercles  in  the  choroid. 
Lumbar  puncture  makes  the  diagnosis  positive. 

What  does  bronchial  breathing  indicate? 

This  is  heard  normally  when  listening  over  the  trachea.     It 


464  DIAGNOSIS  AND  PRACTICE. 

is  encountered  over  airless  spaces  in  the  lung  tissue  and  over 
cavities. 

In  what  diseases  can  we  employ  the  microscope  to  ad= 
vantage  as  an  aid  in  diagnosis? 

Principally  in  diseases  of  the  blood  and  kidney.  It  is  also 
necessary  in  the  examination  of  tumors  and  of  all  secretions 
and  excretions  for  pathogenic  organisms  and  parasites. 

Describe  the  physical  signs  of  simple  ascites  and  those 
of  ovarian  dropsy. 

In  ascites,  if  the  patient  be  lying  upon  the  back,  the  center 
of  the  abdomen  is  flat  (provided  the  amount  of  fluid  is  not 
excessive) ,  the  lateral  and  dependent  portions  bulge.  There 
will  be  tympany  over  the  region  of  the  umbilicus  and  flatness 
in  the  flanks.  Fluctuation  will  be  obtained.  In  dropsy  due 
to  ovarian  disease  the  accumulation  of  the  fluid  is  local  (in 
the  region  of  the  ovary)  ;  it  does  not  change  with  position 
of  the  patient.  If  the  accumulation  be  great,  the  ditferential 
diagnosis  is  very  difficult ;  vaginal  examination  must  be  made, 
and  sometimes  the  character  of  the  dropsy  can  only  be  deter- 
mined from  the  fluid  withdrawn. 

Differentiate  the  early  eruption  of  syphilis  and  measles. 

In  syphilis  there  is  the  history  of  the  chancre,  and  a  period 
of  several  weeks  before  the  eruption  appears.  Coincident 
with  the  eruption  there  is  inflammation  of  the  throat  (mucous 
patches).  There  is  rarely  any  fever.  The  eruption  is  copper- 
colored,  and  is  not  particularly  prominent  on  the  face.  In 
measles  there  is  marked  fever  from  the  onset,  with  severe 
catarrhal  symptoms.  The  eruption  appears  on  the  fourth 
day,  it  occurs  prominently  on  the  face  and  rapidly  spreads 
over  the  body,  the  catarrhal  symptoms  continuing. 

What  are  the  methods  of  physical  diagnosis  or  explora= 
tion? 

Inspection,  palpation,  mensuration,  percussion,  auscultation 
and  succussion. 


DIAGNOSIS  AND  PRACTICE.  465 

Describe  the  symptoms  of  acute  inflammatory  arti= 
cular  rheumatism. 

The  disease,  as  a  rule,  begins  with  pain,  swelling  and  red- 
ness of  one  or  more  of  the  large  joints.  The  joints  implicated 
are  symmetrical.  There  is  moderate  fever,  102^-103°,  acid 
sweats  and  marked  urates  in  the  urine.  There  is  tendency 
to  implication  of  the  serous  membranes  of  the  heart. 

Give  the  etiology  and  describe  the  symptoms  of  idio= 
pathic  erysipelas. 

It  occurs  at  all  seasons  of  the  year  and  in  all  climates.  It 
is  most  liable  to  occur  in  debilitated  and  cachectic  persons 
and  in  the  course  of  chronic  pulmonary  tuberculosis.  The 
disease  may  occur  in  the  puerperal  state.  The  exciting 
<;ause  is  the  streptococcus  erysipelatis  of  Fehleisen.  The  dis- 
ease begins  with  a  chill  or  chilliness,  and  is  followed  by  the 
development  of  the  eruption.  There  are  gastro-intestinal 
symptoms  and  fever.  The  skin  becomes  irritated,  itchy  and 
swollen.  There  is  heat,  tension  and  burning  in  the  part. 
The  eruption  shows  decided  elevation  with  a  distinct,  promi- 
nent margin,  it  is  red  or  puffy  in  the  center  and  glossy  in 
appearance.  Uncomplicated  cases  last  from  two  to  three 
weeks. 

Mention  the  causes  and  describe  the  treatment  of  pri= 
mary  lobar  pneumonia. 

The  exciting  cause  is  the  diplocoecus  or  pneumococcus  of 
Frankel.  Exposure  to  cold  and  wet,  alcohol,  are  said  to  be 
predisposing  causes.  The  treatment  of  the  disease  consists 
in  giving  the  preliminary  purge,  preferably  calomel.  Dover's 
powder  or  a  hypodermic  injection  of  morphine  to  relieve  the 
pleural  pain,  remedies  to  sustain  the  heart  and  respiration, 
such  as  alcohol  and  strychnine,  are  useful.  Ammonium  car- 
bonate and  ammonium  chloride  are  also  of  value. 

Describe  the  treatment  of  hydrothorax. 

Purges,  diaphoretics  and  diuretics  are  of  value.     If  these 
30 


466  DIAGNOSIS  AND  PRACTICE. 

remedies  do  not  relieve  the  condition  the  aspirator  must  be 
resorted  to. 

State  your  treatment,  including  diet,  of  typhoid  fever. 

If  the  patient  be  seen  before  the  tenth  day  of  the  disease, 
a  calomel  purge  should  be  administered.  The  systematic  cold 
bath  of  Brand  is  a  favorite  method  of  treatment.  Alcohol 
and  strychnine  are  valuable  adjuncts  to  sustain  the  circula- 
tion. The  diet  should  be  absolutely  liquid.  Water  plenti- 
fully, milk,  liquid  peptonoids  are  commonly  employed.  No 
solid  nor  semi-solid  food  should  be  administered  before  the 
evening  temperature  has  been  normal  for  at  least  one  week. 

Describe  the  treatment  of  diabetes  mellitus. 

Diet  is  most  important.  No  starches  or  sugars  should  be 
given.  The  diet  should  consist  of  fresh  green  vegetables, 
meat,  fish.  No  alcoholic  or  malt  liquors  should  be  em- 
ployed. The  generally  accepted  treatment  is  by  some  form 
of  opium,  codeine  being  most  often  employed. 

Arsenic  is  of  service. 

Give  the  symptoms  and  treatment  of  tetanus. 

The  prominent  symptoms  are  the  occurrence  and  recurrence^ 
at  varying  intervals,  of  tonic  spasm  of  greater  or  lesser  inten- 
sity in  the  voluntary  muscles.  The  spasm  is  usually  first 
noticed  in  the  neck,  and  this  is  soon  followed  by  spasm  of  the 
muscles  of  the  jaw,  with  inability  to  open  the  mouth.  There 
is  pain,  which,  however,  is  not  severe.  Occasionally  the  body 
arches  backward,  a  condition  known  as  opisthotonos.  There 
is  usually  fever  of  about  101°,  but  after  prolonged  spasm 
hyperpyrexia  may  occur.  The  urine  is  scanty,  extremely 
toxic  and  often  contains  albumin.  Profuse  sweating  is  a 
prominent  symptom.  The  treatment  consists  in  the  endeavor 
to  administer  nutriment,  and  rectal  injections  should  be  re- 
sorted to.  Chloral  is  of  value  because  it  produces  sleep  and 
sometimes  relaxes  spasm.  Antitetanic  serum  is  of  value  in 
some  cases.  The  wound  should  be  thoroughly  cleansed  and 
treated  antiseptically. 


DIAGNOSIS  AND  PRACTICE.  467 

What  is  the  most  common  cause  of  tabes  dorsalis? 

Syphilis. 

How  should  acute  coryza  be  treated? 

Acute  coryza  should  be  treated  by  cleansing  the  nose  with  a 
mild  antiseptic  solution ;  a  weak  solution  of  cocaine  is  also  of 
value.     Dover's  powder  is  also  recommended  internally. 

Describe  the  treatment  of  pleurisy  with  effusion. 

The  common  measures  administered  to  absorb  fluid,  such  as 
purges,  diaphoretics  and  diuretics,  should  be  resorted  to.  If 
these  fail  the  aspirator  may  be  used. 

What  is  the  period  of  incubation  in  variola  and  vaccinia? 

The  period  of  incubation  of  variola  is  from  ten  to  thirteen 
days.  The  period  of  incubation  in  vaccinia  varies  from  three 
to  seven  days,  depending  upon  whether  humanized  or  bovine 
virus  is  used. 

What  are  the  symptoms  of  hepatic  abscess?  In  what 
climate  is  hepatic  abscess  most  likely  to  occur? 

The  symptoms  of  hepatic  abscess  are  an  enlarged  and  tender 
liver,  with  jaundice,  anemia  and  wasting.  The  clinical  mani- 
festations vary,  and  large  abscesses  may  be  present  without 
marked  disturbance.  Occasionally  fluctuation  may  be  de- 
tected in  the  liver.  There  may  be  pain  of  a  throbbing  char- 
acter. Occasionally  all  the  phenomena  of  sepsis  are  present, 
chills,  fever  and  sweating.  The  disease  is  most  common  in 
hot  climates. 

How  may  pleuritis  in  its  early  stages  be  differentiated 
from  intercostal  neuralgia? 

In  pleuritis  there  is  pain,  which  is  especially  aggravated  by 
breathing.  In  intercostal  neuralgia  the  pain  is  over  the  exit 
of  the  intercostal  nerves.  It  is  increased  by  pressure.  In 
pleuritis  the  pain  is  diminished  by  pressure.  The  pain  is  not 
aggravated  in  intercostal  neuralgia  by  deep  breathing.  In 
pleurisy  there  is  a   friction   sound,   which  does  not  occur  in 


468  DIAGNOSIS  AND  PRACTICE. 

intercostal    neuralgia.     Frequently    intercostal    neuralgia    is 
accompanied  by  the  development  of  herpes  zoster. 

How  many  and  what  are  the  stages  of  malarial  inter= 
mittent  fever? 

There  are  three  stages :  The  stage  of  chill,  the  stage  of  fever, 
and  the  sweating  stage. 

Mention  the  eruptive  fevers. 

Scarlet  fever,  measles,  German  or  French  measles  or  rubella, 
variola,  varicella  and  erysipelas,  typhoid  and  typhus  fevers. 

Describe  the  treatment  of  intermittent  fever. 

The  treatment  of  intermittent  fever  consists  in  the  admin- 
istration of  quinine  in  sufficient  doses  to  destroy  the  Plasmo- 
dium of  malaria.  From  10  to  20  grains  a  day  for  an  adult  is 
sufficient  for  this  purpose. 

Give  the  etiology  and  outline  the  treatment  for  acute 
gastritis. 

In  the  majority  of  instances  the  condition  is  due  to  irritants, 
either  thermic  or  chemical,  that  come  in  contact  with  the 
mucous  membrane  of  the  stomach,  producing  an  acute  inflam- 
mation. Food  either  too  hot  or  too  cold,  spices,  drugs  and 
poisons  may  have  this  influence  on  the  mucous  membrane. 
The  treatment  consists  in  the  administration  of  a  purge,  such 
as  calomel  or  castor  oil.  The  diet  should  be  restricted.  In 
severe  eases  it  is  necessary  to  induce  vomiting.  Lavage  is 
useful.     Drugs  are  scarcely  ever  necessary. 

Describe  the  symptoms  and  treatment  of  chronic  hydro= 
cephalus  in  children. 

The  symptoms  of  congenital  hydrocephalus  are  difficulty  in 
the  movements  of  the  child  on  account  of  the  weight  of  the 
head.  As  a  rule  there  is  impairment  of  intellect.  The  head 
is  often  enormous  in  size.  There  may  be  headache  and  dim- 
ness of  vision,  and  the  gait  may  become  irregular.  The  pulse 
is  usually  slow.  Medical  treatment  is  of  no  avail  in  this  con- 
dition.    Operative  methods  are  advised  by  some  authorities. 


DIAGNOSIS  AND  PRACTICE.  469 

Define  rubeola  and  describe  its  symptoms. 

Rubeola  is  an  acute,  infectious,  contagious  disease  charac- 
terized by  marked  catarrhal  symptoms,  especially  of  the  res- 
piratory tract,  with  a  characteristic  eruption  occurring  on  the 
fourth  day.  The  disease  may  begin  with  a  chill,  followed  by 
fever  that  may  reach  103°  F.  or  higher,  with  marked  catarrhal 
symptoms  from  the  onset.  There  is  injected  conjunctiva, 
lachrymation,  photophobia,  coryza,  and  some  cough.  Rales 
are  heard  in  the  chest.  Koplik's  sign  may  appear  about  this 
time.  On  the  fourth  day  the  eruption  appears,  which  consists 
of  rose-red  or  brownish  maculo-papular  points  raised  above 
the  skin,  with  intervening  healthy  skin,  often  arranged  in 
crescentic  shape.  The  eruption  remains  at  its  height  for  about 
four  days.  The  catarrhal  symptoms  continue.  About  the 
eighth  day  of  the  disease  the  eruption  begins  to  fade.  A  fine 
desquamation  occurs.  In  the  absence  of  complications  the 
disease  lasts  about  twelve  days. 

Describe  the  symptoms  and  treatment  of  gangrene  of 
the  lung. 

Cough  accompanied  by  expectoration,  which  is  abundant, 
thin  and  foul-smelling,  should  call  attention  to  gangrene  of 
the  lung.  Fever  is  always  present.  There  is  often  hemop- 
tysis. Microscopically  the  sputum  contains  leukocytes,  shreds 
of  lung  tissue,  especially  elastic  fibers,  fat  crystals  and  bac- 
teria. Upon  percussion  over  the  alfected  area  dulness  is  pres- 
ent. Upon  auscultation,  bronchial  breathing  and,  if  excava- 
tion occurs,  signs  of  a  cavity  are  present.  The  treatment  is 
supportive. 

Describe  the  symptoms  of  tubercular  meningitis. 

The  course  of  the  disease  is  usually  divided  into  a  pro- 
dromal stage,  a  period  of  excitement  and  a  period  of  paralysis. 
In  the  prodromal  stage  the  child  becomes  irritable  and  rest- 
less, there  is  anorexia,  headache,  pain  in  the  limbs,  accom- 
panied by  nausea  and  obstinate  vomiting.  The  second 
stage  is  marked  by  an  aggravation  of  the  symptoms  just 
enumerated,  with  fever.     The  headache  becomes  intense,  and 


470  DIAGNOSIS  AND  PRACTICE. 

is  usually  general.  The  hydrocephalic  cry  is  usually  present. 
Obstinate  constipation  is  characteristic.  There  is  a  rapid 
pulse,  which  may  be  from  120  to  160  per  minute ;  the  abdomen 
is  scaphoid ;  nervous  symptoms  are  present  and,  generally, 
delirium.  The  pupils  are  contracted,  and  strabismus  may 
occur.  There  is  marked  cutaneous  hyperesthesia.  Convul- 
sive movements  are  common.  This  period  lasts  for  a  week  or 
ten  days  and  is  followed  by  the  stage  of  paralysis.  The  fever 
becomes  higher,  often  reaching  105°  or  106°.  Spasmodic 
contractions,  with  tremor  and  twitching  of  the  tendons  and 
muscles,  with  local  paralysis  occur.  The  third  nerve  is  most 
frequently  involved,  causing  ptosis.  The  duration  of  the  dis- 
ease is  variable,  lasting  about  three  weeks.  When  the  disease 
occurs  in  adults  it  may  be  prolonged  to  three  or  four  months. 

What  should  be  done  for  hemoptysis  occurring  in  the 
course  of  phthisis? 

Absolute  quiet  is  essential ;  food  and  drink  should  be  stopped 
for  a  while;  ice-bags  may  be  applied  over  the  chest;  the  ad- 
ministration of  opium  in  some  form  is  generally  advised. 

Give  the  symptoms  of  epidemic  influenza. 

The  disease  occurs  suddenly,  usually  with  a  chill  and  marked 
fever,  103°-105°,  with  catarrhal  symptoms,  such  as  sneezing, 
coughing,  etc.  "There  is  headache,  usually  frontal  or  behind 
the  eyes,  or  at  the  root  of  the  nose,  pain  in  the  limbs  and  in 
the  bones.  There  is  marked  prostration,  out  of  proportion  to 
all  the  other  phenomena.  There  is  a  constant  tendency  to 
complications  resulting  from  inflammation  of  the  respiratory 
or  gastro-intestinal  mucous  membrane.  There  may  be  nau- 
sea and  diarrhea.  Uncomplicated  cases  last  from  a  week  to 
ten  days. 

What  is  hemoptysis? 

Bleeding  from  the  lungs. 

Give  the  physical  signs  of  pleuritic  effusion. 

On  inspection  there  may  be  slight  bulging.     The  apex-beat 


DIAGNOSIS  AND  PRACTICE.  471 

of  the  heart  is  seen  to  be  displaced.  "Upon  palpation  there  is 
decreased  vocal  fremitus.  Upon  percussion  there  is  flatness 
over  the  affected  area.  Upon  auscultation  the  breath-sounds 
are  absent,  and  vocal  resonance  cannot  be  obtained  over  the 
affected  area. 

Describe  the  natural  heart  sounds. 

Two  distinct  sounds  are  encountered :  The  systolic  or  first 
sound,  and  the  diastolic  or  second  sound.  They  are  separated 
from  each  other  by  a  short  pause,  a  long  pause  occurring 
between  the  second  and  first  sound.  The  first  sound  is  due  to 
the  contraction  of  the  ventricle,  the  rush  of  blood  and  the 
closure  of  the  auriculo-ventricular  valve.  It  is  long,  low  and 
booming  in  character.  The  second  sound  is  due  to  the  closure 
of  the  semilunar  valve,  and  is  short  and  valvular.  The  first 
sound  is  best  heard  at  the  apex,  the  second  sound  at  the  base 
of  the  heart. 

On  what  day  does  the  rash  usually  appear  in  scarlatina? 

At  the  end  of  the  first  or  beginning  of  the  second  day. 

What  are  the  symptoms  of  delirium  tremens? 

The  prodromes  consist  of  nervousness,  restlessness  and  ano- 
rexia. As  a  rule  there  is  insomnia.  A  tremor  occurs  which 
affects  the  lips,  tongue  and  limbs.  Delirium  soon  develops, 
which  is  active  and  constantly  changing.  The  skin  is  moist 
and  the  expression  is  anxious.  The  pupils  are  dilated.  The 
temperature  is  subfebrile,  the  pulse  soft  and  rapid.  The 
tongue  is  covered  with  a  thick  fur.  and  there  is  sometimes 
nausea  and  vomiting. 

What  are  the  clinical  features  of  cerebrospinal  fever? 

The  onset  is  sudden,  beginning  with  inten.se  headache,  stiff- 
ness in  the  muscles  of  the  back  of  the  neck,  nausea  and  vomit- 
ing. The  attack  may  begin  with  a  chill.  Delirium  and  stupor 
commonly  occur.  There  is  marked  alteration  of  sensation. 
The  fever  varies  from  101°-105°  or  more.  Kernig's  sign  is 
present.      Herpes    is    very    common.      Other    eruptions    also 


472  DIAGNOSIS  AND  PRACTICE. 

occur,  such  as  erythema,  urticaria  and  petechiae.  Arthritis 
may  be  present.  The  urine  is  scanty  and  may  contain 
albumin.  Special  sense  symptoms  common.  Presence  of 
germ  in  fluid  obtained  by  lumbar  puncture. 

Diagnose  varioloid. 

The  disease  begins  with  a  chill,  followed  by  fever  of  about 
103°.  There  is  nausea  and  vomiting,  pain  in  the  head  and 
back.  The  eruption  occurs  earlier  than  in  variola,  usually  in 
the  course  of  the  second  day.  It  is  never  so  copious.  Th& 
evolution  of  the  pox  is  arrested  in  the  vesicular  stage.  There 
is  no  secondary  fever,  as  there  is  no  pus  to  absorb. 

Give  the  symptoms  of  acute  myelitis. 

Paralysis  of  motion,  which  comes  on  rapidly,  with  complete 
loss  of  sensation  below  the  site  of  the  lesion,  and  paralysis  of 
the  sphincters  are  the  important  symptoms.  Bed-sores  usually 
occur.  There  is  some  rise  in  temperature.  Convulsions  may 
occur.  Reactions  of  degeneration  are  not  present.  The  re- 
flexes are  exaggerated  when  the  lesion  is  above  the  lumbar 
region,  and  ankle  clonus  may  be  elicited.  Loss  of  sensation 
is  complete. 

What  diseases  produce  conditions  of  the  skin  which  are 
of  general  diagnostic  value? 

The  eruptive  diseases,  yellow  fever,  diseases  of  the  liver,, 
purpura,  Addison's  disease  and  melanotic  cancer. 

What  would  auscultation  and  percussion  reveal  in  a  case 
of  congestion  of  the  lung? 

Auscultation  would  reveal  small  moist  rales,  with  broncho- 
vesicular  breathing;  percussion  may  reveal  impairment  of 
resonance. 

What  are  the  physical  signs  of  stenosis  of  the  mitral 
valve? 

A  presystolic  murmur  heard  at  or  near  the  apex,  which  is. 
not  transmitted,  a  presystolic  thrill  and  a  rapid,  irregular, 
feeble  pulse.  The  second  pulmonic  sound  is  greatly  accen- 
tuated. 


DIAGNOSIS  AND  PRACTICE.  473 

Describe  the  features  of  a  case  which  would  lead  you  to 
diagnose  acute  appendicitis. 

Marked  tenderness  and  pain  in  the  right  iliac  fossa,  espe- 
cially over  McBurney  's  point ;  rigidity  upon  the  affected  side ;. 
nausea  and  vomitiug  and  marked  constipation. 

What  does  the  urine  reveal  as  to  color,  specific  gravity^ 
quantity  voided,  abnormal  constituents,  etc.,  in  a  typical 
case  of  diabetes  mellitus? 

The  color  is  pale  yellow  with  a  slight  greenish  cast ;  the  spe- 
cific gravity  is  high,  1030  or  over ;  the  quantity  voided  is  usu- 
ally large,  five  quarts  or  more  in  twenty-four  hours;  the 
abnormal  constituents  consist  in  the  presence  of  glucose;, 
occasionally  there  is  also  albumin. 

State  the  sex  and  period  of  life  to  which  chlorosis  is 
confined. 

It  is  more  common  in  the  female  sex,  rarely  occurring  in  the 
male.     It  is  usual  at  the  age  of  puberty. 

What  are  the  grades  of  temperature  which  come  under 
observation  in  the  sick? 

The  temperature  of  collapse  is  below  96°  ;  subnormal  tem- 
perature is  from  96°-97.5° ;  normal  temperature  is  98.6°  ;  a 
subfebrile  temperature  is  from  99.5°  to  101° ;  moderate  fever 
from  101°  to  103°;  high  fever  from  103°  to  105°;  hyper- 
pyrexia above  105.5°. 

Give  the  most  frequent  causes  of  pericarditis. 

The  most  frequent  causes  are  rheumatic  fever,  scarlet  fever,, 
lobar  pneumonia,  diphtheria,  .septicemia  and  trauma. 

Give  the  symptoms  of  an  ordinary  case  of  scarlet  fever. 

The  disease  begins  suddenly,  with  chill  or  a  convulsion. 
There  is  nausea  and  vomiting,  high  temperature,  rapid  pulse 
and  marked  angina.  There  is  enlargement  of  the  lymphatics 
at  the  angle  of  the  jaw.  At  the  end  of  the  first  or  beginning 
of  the  second  day  an  eruption  appears  all  over  the  body,  which 
has  tlio  ooloi'  of  a  boiled  lobster.     The  eruption  lasts  four  to 


474  DIAGNOSIS  AND  PRACTICE. 

five  days  and  disappears  by  desquamation.     Postscarlatinal 
nephritis  is  a  frequent  complication. 

Describe  an  attack  of  acute  articular  rheumatism. 

The  disease  begins  suddenly,  ^v'ith  fever  of  about  102°-103°. 
There  is  pain,  tenderness,  swelling  and  redness  in  one  or  more 
of  the  large  joints.  Occasionally  prodromes  are  present. 
There  may  be  a  preceding  tonsillitis  or  pharyngitis.  The 
involvement  of  the  joints  is  symmetrical.  The  pulse  is  accel- 
erated, from  100  to  110  per  minute;  the  urine  is  high-colored, 
scanty  in  amount,  specific  gravity  from  1025  to  1040,  contain- 
ing an  abundance  of  phosphates  and  urates,  albumin  being 
rarely  present.  The  saliva  is  strongly  acid.  Copious  acid 
sweats  occur.  Skin  eruptions  are  common,  such  as  urticaria 
and  erythema.     Moderate  leueocytosis  is  the  rule. 

Give  the  differential  diagnosis  between  cerebrospinal 
meningitis  and  typhoid  fever. 

In  the  first  week  of  the  disease  the  diagnosis  is  often  diffi- 
cult. Later  in  enteric  fever  the  characteristic  eruption  ap- 
pears, the  spleen  enlarges,  the  pulse  becomes  dicrotic,  the 
nervous  symptoms  are  not  prominent  until  the  beginning  or 
toward  the  end  of  the  second  week,  the  headache  disappears 
at  the  end  of  the  first  week,  the  Widal  reaction  is  present. 
In  enteric  fever  the  onset  is  rarely  sudden :  there  are  marked 
prodromes,  such  as  headache,  epistaxis;  vomiting  is  very  in- 
frequent ;  the  temperature  curve  in  enteric  fever  is  charac- 
teristic, rising  step-like  in  the  first  week,  being  subcontinuous 
in  the  second,  remittent  in  the  third  and  intermittent  in  the 
fourth  week.  The  onset  in  cerebrospinal  fever  is  sudden, 
with  chill  or  convulsion ;  marked  rigidity  of  the  muscles  of  the 
back  of  the  neck;  violent  headache  and  marked  vomiting  of 
the  cerebral  type.  Herpes  is  common.  The  temperature  is 
not  characteristic,  and  the  nervous  symptoms  are  much  more 
prominent  than  in  enteric  fever. 

What  are  the  physical  signs  of  pulmonary  solidification? 

Upon  palpation  there  is  increased  vocal  fremitus.     Upon 


DIAGNOSIS  AND  F^EACTICE.  475 

percussion  there  is  dulness.  and  upon  auscultation  there  is 
bronchial  breathing.     There  may  be  rales. 

Differentiate  catarrhal  from  croupous  pneumonia. 

Catarrhal  pneumonia  is  a  disease  secondary'  to  bronchitis. 
Croupous  pneumonia  occurs  suddenly,  ^vith  marked  chill,  high 
temperature.  In  croupous  pneumonia  there  is  marked  pain 
in  the  side,  cough,  anxious  expre.ssion  of  the  face,  flush  upon 
the  cheeks,  herpes,  rusty  sputum,  and  the  disease  terminates 
by  crisis,  usually  upon  one  of  the  odd  days  of  the  disease, 
fifth,  seventh  or  ninth  day.  Broncho-pneumonia  occurs  most 
commonly  at  the  extremes  of  age.  The  disease  is  longer  in 
duration,  terminating  by  lysis.  Upon  physical  examination 
in  broncho-pneumonia  there  are  scattered  areas  through  both 
lungs,  over  which  may  be  detected  subcrepitant  rales  and 
dulness.  Croupous  pneumonia  is.  as  a  rule,  a  unilateral  dis- 
ease affecting  the  base  of  the  lung.  The  crepitant  rale,  which 
occurs  in  the  first  stage,  disappears  in  the  second  stage  and 
reappears  in  the  third  stage  as  crepitus  redux.  is  charac- 
teristic. 

Give  the  general  symptoms  of  cerebral  hemorrhage. 

The  onset  is  sudden,  with  loss  of  consciousness,  a  rapid 
development  of  hemiplegia,  conjugate  deviation  of  the  head 
and  eyes,  usually  normal  temperature,  full,  bounding  pulse 
and  irregular  pupils.  There  may  be  Cheyne-Stokes  respi- 
ration. 

What  condition  of  the  blood  is  generally  prominent  in 
all  forms  of  rheumatism? 

There  is  marked  anemia.  The  red  bloodeells  may  be  re- 
duced one-half  or  more  in  number.  The  hemoglobin  may  be 
reduced  to  fifty  per  cent.,  and  leukocytosis  occurs  in  the 
acute  forai. 

What  adventitious  sounds  are  usuall>  discovered  by 
auscultation  in  catarrhal  pneumonia? 

Rales,  usually  of  the  subcrepitant  variety,  large  mucous 
rales  and  broncho-vesicular  breathing. 


476  DIAGNOSIS  AND  PRACTICE. 

How  are  the  lymphatic  glands  involved  in  scarlatina? 

The  lymphatic  glands  at  the  angle  of  the  jaw  and  of  the 
neck  are  usually  enlarged,  sometimes  greatly,  so  that  they 
form  what  is  known  as  the  collar  of  brawn. 

Give  the  physical  signs  of  the  second  stage  of  acute 
lobar  pneumonia. 

There  is  dulness  on  percussion,  bronchial  breathing  on  aus- 
cultation and  sharply  accented  pulmonic  second  sound. 

Give  the  topographical  outlines  of  the  liver  as  revealed 
by  percussion  when  the  patient  is  in  the  recumbent  posi= 
tion. 

Anteriorly  liver  dulness  begins  in  the  mammillary  line  at 
the  sixth  rio,  in  the  axillary  line  at  the  eighth  rib,  and  in  the 
scapular  line  posteriorly  at  the  tenth  rib.  It  extends  from 
all  these  points  to  the  lowest  border  of  the  costal  cartilages. 

At  what  point  does  auscultation  best  reveal  the  sound 
of  the  mitral  valves  and  of  the  aortic  valves? 

The  sound  of  the  mitral  valve  is  best  heard  at  the  apex  of 
the  heart.  The  sound  of  the  aortic  valve  is  best  heard  at  the 
second  right  costal  cartilage  near  the  sternum. 

Make  a  diagnosis  of  locomotor  ataxia. 

The  disease  is  commonly  divided  into  three  stages :  The  pre- 
ataxic,  the  ataxic  and  the  paralytic  stage.  The  pre-ataxic 
stage  is  characterized  by  lightning  pains,  most  often  in  the 
lower  extremities,  by  ocular  phenomena  such  as  the  Argyll- 
Robertson  pupil,  which  is  a  contracted  pupil  reacting  to 
accommodation  but  not  to  light,  and  by  the  loss  of  the  patellar 
tendon-reflex.  In  the  second  stage  the  ataxic  gait  occurs ;  the 
patient  cannot  stand  with  his  feet  in  juxtaposition  with  his 
eyes  closed.  The  symptoms  of  the  pre-ataxic  stage  continue 
in  this  stage.  The  paralytic  stage  is  characterized  at  first  by 
loss  of  control  of  the  sphinctei's  and  by  paralysis. 

Give  the  symptoms  of  acute  spinal  meningitis. 

The  disease  usually  begins  with  chill  and  a  temperature  of 


DIAGNOSIS  AND  PRACTICE.  477 

the  aseptic  type.  There  is  severe  pain  in  the  back,  increased 
by  motion,  radiating  into  the  extremities ;  rigidity  of  the  mus- 
cles occurs.  Hyperesthesia  is  general.  The  reflexes  are  ex- 
aggerated, and  ankle  clonus  is  pronounced.  There  may  be 
retention  of  urine  and  feces. 

What  is  the  period  of  desquamation  in  scarlet  fever? 

The  period  of  desquamation  in  scarlet  fever  usually  occurs 
after  the  appearance  of  the  eruption,  or  when  the  eruption 
has  been  prominent  for  about  four  or  five  days.  It  may  last 
from  several  days  to  several  weeks  or  more.  The  desquama- 
tion is  usually  in  large  scales. 

Define  lithemia. 

A  condition  due  to  a  disturbance  of  metabolism,  character- 
ized by  an  excess  of  uric  acid  in  the  blood,  and  clinically  by 
various  digestive,  nervous  and  circulatory  phenomena. 

What  are  hemic  murmurs  as  applied  to  the  heart,  and 
what  is  their  cause? 

It  is  commonly  believed  that  hemic  murmurs  are  due  to  an 
alteration  in  the  constituents  of  the  blood,  such  as  occurs  in 
chlorosis  or  in  other  forms  of  anemia.  These  murmurs  are 
systolic  in  time,  soft,  and  heard  at  the  left  base  of  the  heart. 

Make  a  general  diagnosis  of  icterus. 

Jaundice  is  characterized  by  a  yellowish  discoloration  of 
the  skin  and  of  the  conjunctiva.  There  is  itching  of  the  skin, 
slow  pulse,  the  appearance  of  bile  pigment  in  the  urine  and 
clay-colored  stools. 

Why  is  dyspnea  caused  by  disorganization  of  the  mitral 
valves? 

This  is  due  largely  to  the  fact  that,  when  rupture  of  com- 
pensation occurs,  the  right  heart,  and  hence  the  pulmonary 
circuit,  is  interfered  with. 

Describe  a  typical  case  of  laryngismus  stridulus. 

Tlie  disease  comes  on   abruptly,   the  cliild  being  attacked 


478  DIAGNOSIS  AND  PRACTICE. 

uiost  ofteu  at  night  with  shortness  of  breath,  followed  by  clos- 
ure of  the  glottis,  which  may  remain  closed  from  several  sec- 
onds to  twenty  or  thirty.  During  this  time  cyanosis  may  be 
a  prominent  feature.  This  is  followed  by  relaxation  of  the 
spasm  giving  rise  to  high-pitched  inspiration.  Convulsions 
may  occur,  and  are  apt  to  be  very  severe. 

Describe  a  typical  case  of  typhus  fever. 

The  disease  begins  suddenly,  with  marked  chill  and  high 
temperature.  There  is  nausea,  vomiting  and  epigastric  pain. 
The  pulse  is  rapid,  hard  and  not  easily  compressible.  Ver- 
tigo and  delirium  soon  set  in.  The  face  is  reddened,  the  pupils 
are  contracted  and  the  conjunctiva  injected.  The  tongue  is 
coated.  The  liver  and  spleen  are  painful  upon  palpation 
and  are  somewhat  enlarged.  Delirium  and  convulsions  are 
common.  Constipation  is  marked  throughout  the  course  of 
the  disease.  On  or  about  the  fifth  day  an  eruption  occurs, 
which,  in  its  early  appearance,  closely  resembles  measles.  It 
occurs  all  over  the  body  except  the  face.  This  eruption  after- 
ward becomes  petechial.  Another  eruption  is  characteristic, 
which  consists  of  marbling  or  mottling  of  the  skin.  On  or 
about  the  fourteenth  day  of  the  disease  crisis  occurs. 

What  is  the  significance  of  prolonged  expiration? 

When  inflammatory  exudates  occur  in  the  bronchial  tubes 
the  expiratory  murmur  equals  and  occasionally  is  longer  than 
the  inspiratory  murmur.  When  this  sign  is  localized  to  the 
apices  it  is  indicative  of  incipient  tubercular  disease.  It  fur- 
ther occurs  in  bronchial  asthma  and  in  chronic  pulmonary 
emphysema. 

What  age  and  sex  are  most  subject  to  chorea? 

It  is  a  disease  of  childhood,  most  common  between  the  fifth 
and  fifteenth  years ;  much  more  common  in  the  female  than  in 
the  male  sex. 

What  is  understood  by  an  exanthematous  fever? 

A  fever  in  which  a  characteristic  eruption  occurs. 


DIAGNOSIS  AND  PRACTICE.  479 

What  parts  of  the  brain  are  most  liable  to  hemorrhage? 

The  parts  supplied  by  the  middle  cerebral  artery. 

Describe  the  morbid  states  associated  with  asthma. 

They  are  chronic  bronchitis  and  chronic  pulmonary  emphy- 
sema, and  hypertrophy  of  the  rght  ventricle. 

What  are  the  general  or  constitutional  symptoms  of 
diphtheria? 

The  onset  of  the  disease  is  rapid,  the  early  symptoms  being 
discomfort  and  weakness,  with  headache.  There  is  moderate 
fever.  Pain  on  swallowing  is  often  the  first  symptom.  Upon 
examination  of  the  tJiroat  the  characteristic  exudate  is  seen. 

What  are  the  physical  signs  of  aortic  regurgitation? 

Upon  inspection  the  apex  of  the  heart  is  found  displaced 
downward  and  to  the  left.  The  impulse  is  seen  to  be  forcible, 
indicating  great  hypertrophy  of  the  left  ventricle.  Palpation 
confirms  this.  Upon  auscultation  a  diastolic  murmur  is  noted 
at  the  second  right  costal  cartilage,  transmitted  down  the 
sternum.  The  Flint  murmur  may  be  present.  The  pulse  is 
characteristic,  being  known  as  Corrigan,  receding  or  water- 
hammer  pulse. 

On  what  day  does  the  rash  usually  appear  in  measles? 

On  the  fourth  day. 

What  is  progressive  pernicious  anemia? 

This  is  a  primary  anemia,  characterized  by  a  marked  de- 
crease in  the  number  of  red  bloodeells,  by  fatty  degeneration 
of  the  heart,  liver  and  kidneys,  and  by  a  peculiar  lemon-yellow 
discoloration  of  the  skin. 

What  is  Asiatic  cholera? 

A  specific  disease,  due  to  the  comma  bacillus  of  Koch,  pre- 
vailing endemically  in  some  parts  of  the  world,  and  occasion- 
ally becoming  epidemic,  characterized  by  vomiting,  purging, 
muscular  cranip  and  higli  mortality. 


480  DIAGNOSIS  AND  PRACTICE. 

Enumerate  the  points  of  diagnostic  value  in  a  case  of 
chronic  interstitial  nephritis. 

Plypertrophy  of  the  heart  and  arteriosclerosis,  albuminuric 
retinitis,  headache,  the  passage  of  large  amounts  of  urine  of 
low  specific  gravity,  1004  to  1006,  traces  of  albumin  and  often 
without  albumin,  and  the  presence  of  tube  casts. 

Name  a  medicine  which  affects  the  urine  as  to  color  and 
odor. 

Turpentine. 

What  cardiac  lesions  are  likely  to  accompany  or  to  fol= 
low  acute  articular  rheumatism?  And  how  may  they  be 
recognized  by  the  aid  of  the  stethoscope? 

Pericarditis  and  endocarditis.  In  endocarditis  a  murmur 
will  be  developed ;  in  pericarditis  a  friction  sound  is  heard. 

How  may  rheumatism  affect  the  respiratory  organs? 

Pleurisy  with  or  vidthout  effusion  may  occur  in  the  course 
of  rheumatic  fever.  Bronchitis  or  pneumonia  may  also  de- 
velop. 

What  is  the  usual  reaction  of  the  urine  in  (a)  chronic 
cystitis,  (b)  acute  articular  rheumatism? 

In  chronic  cystitis  the  reaction  is  usually  alkaline ;  in  acute 
articular  rheumatism  markedly  acid. 

What  is  the  diagnostic  significance  of  dropsy? 

Dropsy  is  an  accumulation  of  watery  fluid  in  one  or  more 
of  the  serous  cavities  or  in  the  subcutaneous  tissues.  It  is  due 
to  venous  obstruction,  to  a  toxemic  condition  of  the  blood,  to 
the  effects  of  inflammation  upon  the  neighboring  circulation, 
to  vasomotor  causes  relating  to  disease  of  the  nervous  system, 
to  lymphatic  obstruction,  and  it  occurs  in  a  condition  known 
as  idiopathic  or  essential  edema. 

Define  a  puerile  murmur  and  give  its  causes. 

This  form  of  breathing  is  normal  in  infants  and  children. 
It  diminishes  in  intensity  up  to  the  age  of  twelve  years.     It 


DIAGNOSIS  AM)  PRACTICE.  481 

closely  resembles  broncho- vesicular  breathing.  However,  the 
ratio  between  the  length  of  inspiration  and  expiration  is 
always  longer.  It  is  ocea.sionally  heard  in  dyspnea,  especially 
from  disease  of  the  heart.  It  also  occurs  in  what  is  known 
as  compensatory  breathing  over  one  lung  when  there  is  disease 
of  the  opposite  lung,  or  in  the  portion  of  one  lung  when  it  is 
affected  by  disease  in  another  part. 

Differentiate  between  sibilant  and  sonorous  rales. 

Sibilant  rales  are  high-pitched,  whistling  rales,  and  occur 
in  the  smaller  bronchial  tubes.  Sonorous  rales  are  low- 
pitched,  snoring  in  character,  and  they  occur  in  the  larger 
bronchial  tubes. 

Name  the  leading  rational  and  physical  signs  of  chronic 
bronchitis. 

The  important  sign  of  chronic  bronchitis  is  cough,  with  or 
without  expectoration.  After  chronic  bronchitis  has  existed 
for  some  time,  emphysema  frequently  occurs,  and  also  bronchi- 
ectasis. The  physical  signs  which  belong  to  chronic  bron- 
chitis are,  particularly,  rales,  which  are  dry  rales  if  there  be 
no  expectoration,  and  moist  rales  if  expectoration  be  profuse. 

Differentiate  between  pulmonary  edema  and  pneumo= 
nitis. 

Pulmonaiy  edema  is  usually  a  secondary  disease.  There  is 
marked  dyspnea,  urgent  and  ti-oublesome  cough,  large  num- 
bei*s  of  moi.st  rales  of  all  sizes  are  heai'd.  particularly  at  the 
base.  In  pneumonitis  there  is  the  onset,  with  chill,  high  tem- 
perature, rusty  sputum,  and  the  important  physical  signs, 
which  consist  in  crepitant  rales,  followed  by  bronchial  breath- 
ing, and  the  crepitus  redux.     The  termination  is  by  crisis. 

In  what  conditions  does  bronchial  breathing  take  the 
place  of  vesicular  breathing? 

Bronchial  Ijrcatliing  is  encountered  over  airless  spaces  in 
the  lung  tissues  and  over  cavities.     Only  pulmonary  tissues 
containing  air  have  the  property  of  changing  into  the  vesi- 
31 


482  DIAGNOSIS  AND  PRACTICE. 

cular  murmur  the  bronchial  sound  as  it  passes  through  the 
trachea  and  bronchi. 

What  is  the  character  of  the  fever  curve  in  chronic 
tuberculosis? 

As  a  rule  it  is  intermittent  in  character.  Occasionally, 
however,  the  inverse  temperature  curve  is  seen. 

What  are  the  physical  signs  in  the  first  stage  of  pneu= 
monic  fever? 

On  inspection  there  is  increased  breathing;  palpation  may 
detect  friction  fremitus  from  the  associated  pleurisy.  On 
percussion  there  is  impairment  of  resonance,  and  on  auscul- 
tation the  crepitant  rale  is  found  to  be  present. 

Relate  the  history  of  a  case  of  progressive  muscular 
atrophy. 

The  early  symptoms  are  pain  in  the  arm  and  shoulder,  with, 
numbness  and  a  feeling  of  exhaustion ;  next  atrophy  is  no- 
ticed, as  a  rule,  in  one  hand.  The  wasting  usually  extends 
and  the  muscles  supplied  by  the  ulnar  nerve  are,  as  a  rule, 
most  aflfeeted.  The  motion  of  the  fingers  becomes  impaired, 
and  the  wasting  gradually  passes  up  from  the  forearm  to  the 
arm  and  shoulder.  Both  flexors  and  extensors  are  affected. 
The  other  hand  usually  shows  the  same  process  within  two  to 
ten  months.  Sometimes  the  muscles  of  the  shoulder  are  first 
affected,  next  the  muscles  of  the  back,  hip  and  thigh  are  in- 
volved. It  is  rare  for  the  muscles  of  the  legs  to  be  attacked. 
There  is  paralysis  and  fibrillary  twitching.  The  reflexes  are 
lost  early.  Reactions  of  degeneration  set  in  later.  One  or 
both  sides  of  the  face  may  be  affected.  The  sphincters  do 
not  share  in  this  process. 

Describe  alcoholism  and  some  of  its  effects. 

As  a  rule,  the  onset  is  insidious,  the  symptoms  consisting  in 
fatigue,  unwillingness  to  work  and  loss  of  energy.  There  ia 
malaise,  headache,  general  and  mental  depression,  loss  of  sleep 
and  tremor  of  the  hands,  lips  and  tongue.     The  tremor  at  firet 


DIAGNOSIS  AND  PRACTICE.  483 

may  be  controlled.  As  the  condition  advances  these  symptoms 
become  more  manifest.  The  skin  becomes  flabby,  the  face  shows 
venous  congestion,  and  acne  may  show  itself  about  the  nose. 
Symptoms  of  gastric  catarrh  are  present  as  a  rule.  The 
tongue  is  flabby  and  furred,  and  the  tremor  is  marked  when 
the  tongue  is  protruded.  Leukoplakia  may  occur,  especially 
in  males.  The  breath  is  fetid,  and  there  is  great  thirst. 
Often  there  is  disgust  for  food,  especially  in  the  morning,  and 
this  is  aggravated  by  the  early  morning  nausea  and  vomiting. 
Insomnia  is  an  early  and  almost  constant  symptom,  and  if  the 
patient  sleep  at  all,  he  is  disturbed  by  bad  dreams.  Peri- 
pheral neuritis  may  develop.  The  will  and  intellectual  facul- 
ties are  greatly  impaired,  and  there  is  perversion  of  the  moral 
tendencies.  The  resistance  of  the  body  becomes  lessened,  so 
that  drinkers  readily  succumb  to  the  acute  infectious  diseases. 

What  is  the  diagnostic  significance  of  Cheyne=Stokes 
respiration? 

This  form  of  respiration  is  very  likely  to  be  observed  in 
disease  of  the  brain,  from  disturbances  of  the  circulation  or 
from  toxic  conditions. 

State  where  topographically  mitral  and  tricuspid  mur= 
murs  are  most  distinctly  heard. 

The  mitral  murmur  is  heard  at  or  near  the  apex.  The  tri- 
cuspid murmur  is  heard  a  little  to  the  right  of  the  ensiform 
cartilage. 

Enumerate  the  diagnostic  sounds  in  a  diseased  respi= 
ratory  apparatus. 

There  may  be  moist  or  dry  rales,  crepitant  rales,  friction 
sounds,  bronchial  breathing,  broncho-vesicular  breathing  or 
cavernous  breathing. 

In  what  conditions  does  sub-normal  temperature  occur? 

This  occurs  in  diabetes,  myxedema,  chronic  cardiac,  renal 
and  hepatic  disease,  and  in  many  forms  of  insanity.  It  is 
also  common   in   internal   malignant   growth.     It   frequently 


484  DIAGNOSIS  AND  PRACTICE. 

occurs  after  the  defervescence  in  some  of  the  specific  fevers. 
It  occurs  in  the  stage  of  collapse  in  cholera. 

How  does  paralysis  of  the  third  nerve  affect  the  eye? 

There  may  be  ptosis,  slight  exopthalmos,  external  stra- 
bismus, diplopia  and  a  dilated  pupil  which  reacts  neither  to 
accommodation  nor  to  light. 

Give  the  cause  and  clinical  features  of  purpura  sim= 
plex. 

This  condition  occurs  in  many  diseases.  It  is  characterized 
by  the  extravasation  of  blood  into  the  skin,  mucous  membranes 
and  internal  organs,  and  sometimes  by  free  hemorrhage  from 
mucous  membranes.  The  alterations  in  the  composition  of 
the  blood  in  purpura  are  usually  those  of  symptomatic  ane- 
mia from  hemorrhage.  Purpura  simplex  is  most  usually 
met  with  in  children.  It  is  a  mild  condition,  accompanied 
with  purpuric  spots  upon  the  extremities,  and  sometimes 
upon  the  trunk  and  arms,  with  impairment  of  the  appetite 
and  diarrhea. 

Make  a  diagnosis  of  cerebral  tumor. 

The  characteristic  symptoms  consist  in  headache,  optic 
atrophy,  sensory  disturbances,  convulsions,  vomiting,  vertigo 
and  bradycardia.  The  headache  is  almost  constant,  and  in- 
creases in  severity  as  the  disease  advances.  It  may  often  be 
diffuse,  occupying  the  entire  skull.  Double  optic  neuritis  is 
very  frequent.  The  temperature  is  usually  normal  or  sub- 
normal. If,  however,  the  tumor  be  situated  in  the  pons  or 
medulla  there  may  be  hyperpyrexia.  Occasionally  there  is 
dyspnea,  and  also  Cheyne-Stokes  respiration.  Yawning  and 
hiccough  occur. 

Describe  the  skin  appearances  in  (a)  rubeola,  (b)  ru= 
bella,  (c)  scarlatina  and  (d)  varicella. 

(a)  In  rubeola  the  eruption  appears  upon  the  fourth  day. 
It  is  maculo-papular  and  coarse.  It  appears  all  over  the  body, 
and  is  particularly  marked  upon  the  face.  It  is  sometimes 
arranged  in  crescentic  form.     It  disappears  by  fine  desqua- 


DIAGNOSIS  AND  PRACTICE.  485 

mation.  (b)  In  rubella  the  eruption  oeeure  upon  the  first  day 
irregularly  over  the  face,  neck,  chest,  body  and  limbs.  It  is 
a  multiform  eruption,  and  may  resemble  erythema,  urticaria, 
and  in  some  cases  even  measles  and  scarlet  fever.  It  may  be 
confluent  or  diffuse,  and  usually  lasts  from  two  to  four  days. 
Desquamation  occurs  in  fine  scales,  (c)  In  scarlatina  the 
eruption  appears  at  the  end  of  the  first  day  or  beginning  of 
the  second  day.  It  is  a  bright  scarlet  eruption,  being  a  true 
inflammation  of  the  skin.  It  disappears  by  desquamation, 
which  is  often  in  large  scales,  an  entire  cast  of  a  hand  or  foot 
coming  away,  (d)  The  eruption  in  varicella  appears  upon 
the  first  day,  the  exanthem  showing  itself  as  small  reddish 
points  or  papules,  which  in  a  few  hours  become  vesicles.  The 
eruption  is  slightly  elevated  above  the  skin,  rather  than  hav- 
ing the  appearance  of  being  under  the  skin.  The  vesicles  are 
thin  and  transparent,  and  from  i/g  to  1^4  of  an  inch  in  diam- 
eter. The  contents  are  at  first  clear  and  transparent.  As  a 
rule  there  is  no  areola.  In  the  course  of  a  few  hours  the  vesi- 
cle becomes  milky,  and  begins  to  shrivel.  The  pox  may  appear 
upon  the  face,  neck,  scalp,  and  some  parts  of  the  trunk. 

In  what  diseases  may  blood  be  expectorated? 

As  a  rule  it  occurs  in  chronic  pulmonary  tuberculosis.  It 
sometimes  occurs  in  croupous  pneumonia.  It  may  result  from 
cancer  of  the  lungs,  from  abscess  of  the  lung,  from  bronchi- 
ectasias,  ulcerative  lesions  of  the  bronchi  and  in  disease 
of  the  mitral  valve.  It  may  occur  from  aortic  aneurysm. 
Malignant  disease  and  parasites  of  the  lung  also  give  rise  to 
it.  Vicarious  hemorrhage.  It  may  occur  in  the  hemorrhagic 
diathesis,  in  purpura  and  trauma  of  the  chest  wall. 

Give  the  period  of  incubation  and  of  eruption  of  the 
exanthemata. 

The  period  of  incubation  in  scarlet  fever  is  from  two  to 
seven  days.  The  eruption  occurs  at  the  end  of  the  fii-st  or 
beginning  of  the  second  day.  The  period  of  incubation  in 
measles  is  about  ten  days.     The  eruption  occurs  on  the  fourth 


486  DIAGNOSIS  AXD  PRACTICE. 

day.  The  period  of  incubation  of  rubella  is  about  eighteen 
days.  The  eruption  appears  upon  the  first  day.  The  period 
of  incubation  in  variola  is  from  ten  to  thirteen  days.  The 
eruption  appears  upon  the  third  day.  The  period  of  incu- 
bation of  varicella  is  from  ten  to  fifteen  days.  The  eruption 
appears  upon  the  first  day. 

Make  a  differential  diagnosis  between  renal  colic  and 
hepatic  colic. 

The  pain  in  biliary  colic  radiates  over  the  upper  half  of  the 
abdomen  toward  the  right  shoulder.  There  is  tenderness  over 
the  gall-bladder.  The  pain  in  renal  colic  radiates  less  over 
the  abdomen,  but  is  marked  down  the  ureter  to  the  testicles 
and  to  the  head  of  the  penis,  often  irritating  the  rectum. 
There  is  tenderness  over  the  kidney  and  in  the  lumbar  region. 
In  biliary  colic  the  vomiting  is  pronounced  and  persistent. 
In  renal  colic  vomiting  may  be  present,  but  is  never  persistent. 
In  biliary  colic  there  are  no  symptoms  relating  to  the  bladder 
or  testicle.  In  renal  colic  these  symptoms  are  marked.  The 
urine  may  contain  bile  in  biliary  colic.  In  renal  colic  the 
urine  may  contain  blood  and  mucus.  Jaundice  is  present  in 
biliary  colic,  and  absent  in  renal  colic. 

Mention  and  describe,  in  regard  to  the  feces,  abnormal 
conditions  that  are  of  diagnostic  value. 

Large  quantities  of  mucus  may  be  present  in  the  evacua- 
tions, showing  a  catarrhal  condition  of  the  mucous  membrane 
of  the  intestine.  Fat  may  occur  in  the  stools,  and  be  due  to 
disease  of  the  pancreas.  Blood  occurs  from  hemorrhage  in 
the  intestine.  Pus  may  occur  from  the  rupture  of  an  abscess 
situated  anywhere  in  the  intestinal  tract.  Gall-stones  and 
enteroliths  are  also  diagnostic.  Shreds  of  tissue  and  fibrinous 
casts  from  necrosis  occasionally  occur.  They  may  be  due  to 
carcinoma  of  the  bowel.  Fibrinous  casts  occur  particularly 
in  the  course  of  dysentery.  Various  forms  of  animal  para- 
sites may  also  be  found  in  the  stools. 


DIAGNOSIS  AND  PRACTICE.  487 

Give  the  symptomatology  of  epilepsy. 

As  a  rule  the  attack  comes  on  suddenly,  the  patient  falling 
to  the  ground  unconscious.  This  may  or  may  not  be  preceded 
.  by  an  aura.  At  first  there  are  tonic  spasms,  the  patient  often 
biting  his  tongue  and  bloody  foam  appearing  at  the  mouth. 
This  is  followed  by  clonic  spasm,  and  this  in  turn  is  succeeded 
by  epileptic  coma.  During  the  attack  the  pupils  are  markedly 
dilated.  After  the  attack  the  patient  usually  falls  into  a 
deep,  profound  sleep  lasting  for  several  hours. 

Make  a  diagnosis  of  infantile  spinal  paralysis. 

The  disease  begins  suddenly,  often  with  convulsions,  de- 
lirium and  fever.  The  temperature  rises  suddenly,  usually  to 
about  103^  F.,  there  is  pain  in  the  back  and  limbs,  and  some- 
times diarrhea.  Paralysis,  as  a  rule,  occurs  suddenly.  The 
paralysis  is  more  extensive  early  and  the  muscles  of  the  par- 
alyzed limb  soon  undergo  atrophy.  Reactions  of  degenera- 
tion are  marked.  The  legs  are  most  often  attacked.  Later, 
as  a  rule,  marked  improvement  takes  place. 

How  may  pleuritic  friction  sounds  be  distinguished  from 
rales  occurring  in  the  bronchial  tubes? 

A  friction  sound  is  close  to  the  ear;  it  is  distinctly  localized, 
and  accompanied  by  pain  on  respiration.  It  may  occur  in 
inspiration  or  in  expiration  or  in  both.  As  a  rule  there 
is  no  pain  with  rales;  they  are  further  from  the  ear  and 
are  more  diffused  over  the  chest.  Coughing  has  no  effect  upon 
pleuritic  friction  but  causes  rales  to  disappear. 

What  complication  should  be  guarded  against  in  inflam- 
matory conditions  of  the  ear? 

The  most  important  complication  relates  to  an  affection  of 
the  meninges.  This  is  more  apt  to  result  from  disease  of  the 
middle  ear. 

Define  cyanosis  and  give  its  causes. 

This  is  a  blue-red  condition  of  the  skin,  showing  itself  most 
prominently  upon  those  parts  that  are  normally  bright  red, 


488  DIAGNOSIS  AND  PRACTICE. 

such  as  the  lips,  cheeks,  mucous  membranes  and  the  finger- 
nails. Cyanosis  is  due  to  the  accumulation  of  carbonic  acid 
in  the  blood  and  a  deficient  amount  of  oxygen,  the  blood  hav- 
ing a  venous  or  hypervenous  character. 

It  may  result  from  concentration  of  the  blood,  as  in  cholera ; 
in  polycythemia,  from  excess  of  hemoglobin. 

It  is  most  constant  in  lung  stasis  and  weakness  of  the 
right  ventricle. 

What  aids  to  diagnosis  are  utilized  in  the  treatment  of 
persons  affected  with  stomach  lesions? 

Inflation  of  the  stomach  may  be  practiced  so  as  to  determine 
the  size  and  position  of  the  stomach.  The  X-ray  may  be  used. 
A  test  meal  may  be  given,  and  the  contents  of  the  stomach 
withdrawn  after  a  certain  time.  The  contents  are  then  tested 
for  free  HCl,  pepsin,  lactic  acid,  etc.  The  stomach  tube 
determines  gastrectasis. 

State  possible  causes  of  dropsical  conditions  of  the 
abdomen  and  lower  extremities. 

This  is  most  often  due  to  disease  of  the  heart,  kidneys  and 
liver.  It  occasionally  occure  from  profound  anemia,  and  may 
be  due  to  pressure  in  the  abdomen,  as  from  malignant  disease 
or  aneurysm. 

What  causes  general  anemia?  Make  a  diagnosis  of 
general  anemia. 

By  the  term  anemia  is  meant  a  deficiency  of  the  blood, 
either  in  its  bulk  or  in  certain  of  its  constituents.  It  is  usually 
divided  into  primary  and  secondary  anemia.  By  the  term 
primary — also  called  essential,  idiopathic  or  cryptogenetic — 
anemia  is  meant  a  disturbance  of  the  blood  or  blood-making 
organs,  so  that  the  anemia  seems  the  distinctive  feature  of  the 
disease,  while  other  symptoms  appear  mainly  dependent  upon 
this  change.  Secondary  anemia  is  due  to  some  disease  acting 
upon  the  blood  or  blood-making  organs,  the  anemia  not  being 
the  prime  feature,  but  a  symptomatic  manifestation.  The 
diagnosis  depends  upon  a  change  in  the  blood  itself,  either  in 


DIAGNOSIS  AND  PRACTICE.  489 

a  diminution  in  the  hemoglobin  or  in  the  number  of  blood 
corpuscles,  or  a  change  in  both  these  constituents.  There  are 
also  constitutional  symptoms,  such  as  pallor,  shortness  of 
breath,  especially  upon  exertion,  digestive  disturbances  and 
nervous  symptoms.     Edema  of  ankles. 

Mention  and  differentiate  the  species  of  tenia. 

In  man  three  species  of  tapeworm  which  are  fully  developed 
commonly  occur.  The  tenia  echinococcus  occurs  only  in  its 
laical  form.  The  three  varieties  are  tenia  solium,  tenia 
saginata  and  the  bothriocephalus  latus  or  tenia  latus.  The 
tenia  solium  is  sometimes  called  the  armed  tapeworm,  as  the 
rostellum  is  supplied  with  two  rows  of  booklets,  each  row 
containing  from  twelve  to  fourteen  booklets.  The  head  is 
quadrilateral,  being  supplied  with  four  suctorial  discs.  The 
worm  is  about  four  meters  long.  The  segments  are  from  6-8 
mm.  in  breadth  and  from  10-12  mm.  in  length.  In  the  tenia 
saginata  the  head  is  surrounded  by  four  suckere,  with  a  rudi- 
mentary sucker  in  the  middle.  The  segments  measure  from 
8-10  mm.  in  width  and  are  about  18  mm.  in  length.  In  the 
tenia  lata  the  worm  varies  from  5-16  meters  in  length.  The 
head  is  elongated,  and  supplied  with  two  grooved  suckers,  one 
on  each  side.  The  breadth  (1.8  cm.)  of  the  joints  is  greater 
than  the  length.  The  mature  segments  show  a  rosette  ar- 
rangement of  the  uterus  which  is  characteristic. 

Describe  the  Brand  method  of  treatment  in  typhoid 
fever. 

When  the  temperature  in  the  axilla  reaches  102.6°  F.  a  cold 
bath  is  given,  and  repeated  every  three  hours,  the  water  being 
at  a  temperature  of  about  70°  F.  The  patient  should  be 
immersed  in  the  tub,  the  water  covering  all  but  the  head ;  then 
water  of  a  lower  temperature  should  be  poured  upon  the 
patient's  head  or  a  wet  ice  pack  used.  Gentle  friction  should 
be  applied  constantly  by  the  attendants,  and  the  patient 
should  be  encouraged  to  do  likewise.  The  abdomen  should 
not  be   rubbed.      The  duration  of  the   bath   is   If)   minutes. 


490  DIAGNOSIS  AND  PRACTICE. 

Some  alcoholic  stimulant  should  be  administered  to  the  pa- 
tient before  and  after  the  bath.  When  the  bath  is  finished 
the  patient  should  be  lifted  back  to  his  bed  and  covered  with 
woolen  blankets.  The  temperature  should  be  taken  one-half 
hour  afterward  to  note  the  fall  produced  by  the  bath. 

Give  the  symptoms  and  treatment  of  myocarditis. 

The  symptoms  may  be  entirely  latent,  and  the  condition  in 
mild  grades  is  not  likely  to  be  recognized.  In  the  advanced 
stages  pain  in  the  precordium,  especially  upon  slight  exertion, 
becomes  prominent.  It  radiates  and  shoots  down  the  left 
arm,  and  tingling  may  oecur  in  the  fingers.  Shortness  of 
breath  is  a  prominent  symptom.  The  apex  beat  is  weak  and 
diffused,  the  pulse  is  feeble,  and  often  intermittent.  Marked 
arrhythmia  occurs.  Constipation  and  gastric  disturbances 
are  common.  In  advanced  stages  edema  of  the  skin  may 
occur.  The  treatment  consists  in  careful  regulation  of  the 
diet,  attention  to  the  functions  of  the  body,  and  the  systemic 
use  of  such  drugs  as  alcohol,  strychnia,  iodide  of  potassium 
and  arsenic. 

What  is  the  practical  import  of  hematuria,  and  how  can 
its  source  be  diagnosed? 

Blood  in  the  urine  may  be  from  the  kidneys,  in  calculi 
acute  nephritis,  after  powerful  diuretics,  etc. ;  from  the  blad- 
der, in  diphtheritic  and  acute  cystitis,  calculi,  cancer,  conges- 
tion, etc. ;  from  the  prostate  and  as  a  result  of  mechanical  in- 
jury. When  blood  is  derived  from  the  bladder  the  first  that 
is  passed  will  contain  a  smaller  amount  of  blood  than  the  last. 
Blood  from  the  bladder  may  be  copious  in  amount,  and  this 
urine  in  contrast  to  that  containing  blood  from  the  kidney, 
upon  standing,  will  show  fibrin.  Blood  from  the  kidney  is 
more  likely  to  be  intimately  mixed  with  the  urine,  which  is 
acid  in  reaction,  and  if  coagula  be  present  they  are  apt  to  be 
washed  out.  From  the  urethra  only  the  last  drops  are  likely  to 
be  bloody. 


DIAGNOSIS  AND  PRACTICE.  491 

Give  the  etiology  of  scarlet  fever. 

Age  is  an  impoi'tant  predisposing  cause.  It  rarely  occui*s 
after  the  tenth  year  of  life.  Neither  sex  nor  occupation  pre- 
dispose to  it.  The  disease  is  more  common  in  cold  and  tem- 
perate regions.  Epidemics  are  more  prevalent  in  the  winter. 
In  this  disease  there  is  a  marked  personal  predisposition. 
One  attack  confei-s  immunity  as  a  rule.  The  exciting  cause 
is  not  known. 

Give  the  treatment  of  tic  douloureux. 

It  is  especially  important  to  treat  the  underlying  condition. 
If  the  disease  be  reflex  it  is  important  to  give  attention  to  the 
aflt'eetion  giving  rise  to  it.  Hygienic  treatment  is  of  import- 
ance. Change  of  scene  and  residence,  with  good,  nourishing 
diet,  are  necessary.  Many  drugs  have  been  recommended  for 
the  treatment  of  the  paroxysm,  such  as  quinine,  the  coal-tar 
analgesics,  the  salicylates,  caffeine,  aconite,  gelsemium  and 
belladonna.  Morphine  should  be  avoided  if  possible,  as  there 
is  great  danger  of  the  patient  acquiring  the  opium  habit. 
Local  treatment  is  sometimes  of  use,  thus  hot  and  cold  appli- 
cations, liniments  containing  menthol,  and  occasionally  elec- 
tricity may  be  tried.  In  protracted  cases  surgical  interfer- 
ence should  be  thought  of. 

Give  the  symptoms  of  appendicitis. 

The  onset  is  .sudden ;  there  is  pain  in  the  abdomen,  which  at 
first  may  be  general  or  centered  around  the  umbilicus,  and 
■occasionally  in  the  epigastrium  and  in  the  left  or  right  iliac 
fo.ssa.  In  many  cases  the  pain  is  confined  to  the  right  iliac 
fossa,  and  directly  in  the  region  of  the  appendix  (McBurney's 
point).  If  the  pain  is  general  it  soon  localizes  itself  in  the 
right  iliac  fossa,  usually  within  the  course  of  twenty-four 
hours.  It  is  paroxysmal  or  intermittent,  and  colic-like.  This 
pain  may  be  preceded  by  chilliness.  Frequently  nausea  and 
vomiting  mark  the  beginning  of  the  attack.  Fever  rapidlj'^ 
follows  the  onset  of  the  disease,  and  is  usually  moderate, 
from  100°-103°  F.     Occa.sionally  it  may  l>e  absent.     The  fre- 


492  DIAGNOSIS  AND  PRACTICE.    ■ 

queney  of  the  pulse  generally  corresponds  to  the  degree  of 
the  fever.  Constipation  is  commonly  present.  The  tongue 
is  coated  posteriorly.  The  facial  expression  of  the  patient 
shows  anxiety  and  sutfering.  The  position  of  the  patient  is 
often  characteristic.  The  right  thigh  is  frequently  partially 
flexed  upon  the  abdomen,  while  the  left  leg  is  extended. 
Examination  of  the  abdomen  shows  slight  distension.  On 
palpating  the  abdomen  the  right  rectus  muscle  will  be  found 
rigid.  Tenderness  is  as  constant  as  pain.  Pressure  upon 
the  opposite  side  produces  pain  in  the  region  of  the  appendix. 
In  some  instances  the  appendix  may  be  clearly  made  out,  and 
occasionally  a  tumor  is  palpable. 

Define  aphasia  and  give  its  etiology. 

Aphasia  embraces  a  variety  of  defects  in  the  use  or  the 
comprehension  of  language,  either  spoken  or  written.  In  the 
majority  of  cases  aphasia  is  one  of  the  symptoms  of  organic 
local  cerebral  disease,  occurring  in  the  left  hemisphere  in  the 
right-handed,  and  vice  versa.  It  occure  in  cerebral  hemor- 
rhage, thrombosis,  embolism,  abscess,  tumor,  and  depressed 
fracture  of  the  skull.  Rarely  it  has  been  noted  in  hysteria 
and  neurasthenia. 

Give  the  diagnosis  and  treatment  of  acute  follicular 
tonsillitis. 

The  diagnosis  depends  upon  great  pain  in  swallowing.  This 
may  be  preceded  by  lassitude,  malaise,  headache,  pain  in  the 
bones,  vomiting,  and  marked  fever.  Examination  of  the 
throat  shows  redness  and  swelling  of  one  or  both  tonsils,  with 
yellowish-white  patches  upon  them,  varying  in  size  from  a 
pin-head  to  a  split  pea.  These  may  be  stripped  off  without 
leaving  a  bleeding  surface,  leaving  an  intact  mucous  mem- 
brane beneath.  The  breath  is  usually  fetid.  The  patient 
should  be  put  to  bed  and  a  laxative  administered.  The  coal- 
tar  products,  especially  phenacetine,  in  small  doses,  guardedly 
given,  promptly  relieve  the  pain.  Ice  bandages  and  small 
particles  of  ice  in  the  mouth  are  useful.     If  pain  and  sleep- 


DIAGNOSIS  AND  PRACTICE.  493 

lessness  persist,  opium,  especially  Dover's  powder,   may  be 
administerd. 

Give  the  treatment  of  intestinal  hemorrhage  in  typhoid 
fever. 

Food  and  drink  should  be  withdrawn ;  one  or  more  ice-bags 
applied  to  the  right  iliac  fossa,  and  opium  given  for  effect. 
The  head  of  the  bed  may  be  lowered  and  the  foot  of  the  bed 
elevated.  The  opium  should  be  pushed  so  as  to  produce 
mild  somnolence.  If  thirst  becomes  excessive,  small  pellets 
of  ice  may  be  placed  in  the  mouth  from  time  to  time. 

Hypodermoclysis  is  indicated  if  the  hemorrhage  is  pro- 
fuse or  recurs. 

Give  the  treatment  of  delirium  tremens. 

One  of  the  most  important  features  in  the  treatment  is  care- 
ful feeding.  Little  food  should  be  given  at  a  time,  but  it 
should  be  frequently  administered.  If  vomiting  is  pereistent. 
rectal  alimentation  may  be  resorted  to.  If  there  are  signs  of 
heart  failure  stimulants  must  be  administered.  Strychnine 
hypodermically  is  of  great  value.  Every  effort  should  be 
made  to  induce  sleep.  The  most  useful  agents  are  morphine 
hypodermically,  or  hyoscine.  Chloral  is  also  useful,  but  it  ha,s 
a  depressing  effect  upon  the  heart. 

Give  the  treatment  and  prognosis  of  progressive  perni- 
cious anemia. 

Rest  in  bed  is  essential,  and  easily  digested,  nutritious  foods 
should  be  given.  Arsenic  has  been  found  of  most  value,  given 
in  the  form  of  Fowler's  solution  in  ascending  doses.  If  this 
drug  is  not  well  borne  iron  may  be  substituted.  Bone  marrow 
is  also  useful.  Stimulants,  such  as  strychnine  and  alcohol, 
and  inhalations  of  oxygen,  are  of  advantage.  The  prognosis 
is  always  grave.  Death  results  in  from  a  few  months  t^  a  few 
years.     Apparent  recovery  followed  by  relapse  is  common. 

Give  the  symptoms  of  acute  exudative  nephritis. 

The  disease  may  begin  suddenly  or  gradually.       Edema 


494  DIAGNOSIS  AND  PRACTICE. 

develops  rapidly.  The  urine  becomes  scanty  and  high  col- 
ored, and  uremic  symptoms,  such  as  vomiting  and  convulsions, 
occur.  The  edema  at  first  is  most  marked  in  the  face,  partic- 
ularly about  the  eyelids.  There  is  dull  headache,  with  pain 
in  the  back  and  loins,  dryness  of  the  skin  and  dyspnea.  The 
temperature  is  sub-febrile.  The  urine  upon  examination 
shows  that  it  is  decreased  in  amount,  the  color  is  dark  red  and 
is  turbid,  blood  being  present.  The  specific  gravity  is  from 
1020  to  1030,  and  upon  testing  the  urine  large  quantities  of 
serum  albumin  are  found.  The  quantity  of  urea  is  usually 
less  than  normal.  Under  the  microscope  hyaline,  granular 
and  epithelial  casts  are  noted,  witJi  renal  epithelium,  red  blood 
cells  and  granular  matter. 

Define  and  describe  bronchorrhea. 

This  is  a  rare  form  of  bronchitis,  characterized  by  an  exces- 
sive amount  of  secretion,  Avhich  is  very  foul.  It  is  sometimes 
called  purulent  bronchorrhea.  The  quantity  of  expectoration 
varies  from  one  to  three  pints.  The  character  may  be  either 
thin  or  watery  or  it  may  be  transparent  or  ropy.  Dyspnea 
and  cough  are  always  present,  often  being  persistent  and 
paroxysmal. 

Define  hydro=nephrosis.  State  its  causes  and  describe 
its  treatment. 

Obstruction  to  some  part  of  the  ureter,  bladder  or  urethra 
may  give  rise  to  dilatation  ot  the  pelvis  and  tubules  of  the 
kidney  from  accumulation  of  urine.  It  may  be  due  to  the 
twisting  of  the  ureter,  it  may  result  from  congenital  narrow- 
ing of  the  ureter  or  urethra,  from  pressure.  The  treatment 
is  largely  surgical.  Massage  may  be  practiced  with  favorable 
results.  However,  if  the  condition  persists,  aspiration  and 
drainage  are  necessary. 

Give  the  symptoms  and  treatment  of  migraine. 

The  principal  symptom  is  the  headache,  which  shows  greater 
or  less  periodicity.  This  symptom  is  followed  by  pallor  and 
some  vasomotor  spasm.     As  a  rule  the  disease  is  unilateral^ 


DIAGNOSIS  AND  PRACTICE.  495 

the  left  side  being  oftener  affected  than  the  right.  The  pupil 
upon  the  affected  side  is  often  smaller,  and  the  eye  may  be 
retracted.  Often  there  is  disturbance  of  vision,  the  duration, 
however,  being  temporary.  Occasionally,  tinnitus  aurium 
occurs,  which  may  be  associated  with  vertigo.  These  symp- 
toms are  accompanied  in  the  majority  of  cases  by  marked 
gastric  disturbances,  such  as  nausea,  with  frequent  vomiting. 
The  treatment  consists  in  relieving  the  pain  and  the  preven- 
tion of  its  recurrence.  The  following  drugs  have  been  recom- 
mended: Ergot,  the  coal-tar  products,  salicylate  of  sodium,, 
the  bromides,  caffeine  and  gelsemium.  As  a  prophylactic, 
nitroglycerin  taken  after  meals  with  bismuth  and  pepsin  has. 
been  said  to  be  of  value.  Mild  purging  with  calomel  from 
time  to  time  often  prevents  attacks. 

Mention  a  disease  of  the  nervous  system  in  which  the 
patella  reflex  usually  disappears;  one  in  which  it  is  usually 

exaggerated. 

In  locomotor  ataxia  the  knee-jerk  usually  disappears;  in 
spastic  paraplegia,  as  a  rule,  the  knee-jerk  is  exaggerated. 

Define  myxedema  and  give  its  treatment. 

This  is  a  disease  characterized  by  a  myxomatous  change  in 
the  subcutaneous  tissues  due  to  pathologic  lesions  in  the  thy- 
roid gland  of  the  adult  causing  diminished  or  absent  secretion. 
Thyroid  extract  should  be  administeired  as  early  as  possible, 
and  should  be  continued  until  all  the  symptoms  disappear,  and 
then  a  prophylactic  dose  must  be  given  regularly.  General 
tonics,  such  as  iron,  quinine  and  strychnia,  are  of  value. 

Define  simple  acute  stomatitis;  at  what  age  is  it  most 
common  and  what  is  its  treatment? 

This  is  an  iuflanimation  of  the  nuicous  membrane  of  the 
moutli.  The  disease  is  most  frequent  in  children,  but  may 
also  occur  in  adults.  The  treatment  consists  in  cleanliness, 
cai'oful  feeding,  and  the  use  of  a  mild  alkaline  mouth  wash. 
A  mild  purge  is  often  advantageous. 


496  DIAGNOSIS  AND  PRACTICE. 

Give  the  causes  and  treatment  of  bronchial  asthma. 

The  disease  is  sometimes  hereditary.  It  is  more  common 
in  males  than  in  females.  It  may  follow  an  attack  of  bron- 
chitis, and  is  commonly  associated  with  chronic  bronchitis 
and  emphysema.  The  inhalation  of  dust,  the  pollen  of 
certain  plants,  fog,  fumes,  vapors,  odors  that  emanate  from 
certain  animals  may  produce  an  attack  of  asthma.  Reflex 
causes,  as  irritation  from  nasal  polypi,  causes  relating  to  the 
gastro-intestinal  tract,  skin  or  genito-urinary  center  may  act 
in  a  like  manner.  For  the  treatment  of  the  paroxysm  nar- 
cotics and  anti-spasmodics  are  usually  employed.  Chloral, 
whiffs  of  ctiloroform  or  ether,  amyl  nitrite  by  inhalation,  or 
morphia  and  atropia  hypodermically  are  useful  drugs.  Re- 
lief sometimes  follows  the  inhalation  of  nitre-paper  cigarettes, 
which  also  contain  lobelia  and  stramonium.  Sinapisms  and 
turpentine  stupes  to  the  chest  may  be  of  value. 

Give  the  treatment  of  an  acute  attack  of  gout. 

A  mild  laxative  at  the  onset  is  useful.  The  affected  joint 
should  be  kept  at  rest,  and  a  diet  of  milk  and  farinaceous 
articles,  with  plenty  of  water,  should  be  insisted  upon.  If 
the  pain  become  severe  opium  in  some  form  must  be  adminis- 
tered. For  the  attack  itself  colchicum  is  the  remedy.  Iodide 
and  bromide  of  potassium  are  also  useful,  as  are  also  the 
salicylates  and  the  salts  of  lithia. 

State  the  prognosis  in  aneurysm  of  the  thoracic  aorta. 

The  prognosis  is  always  grave,  death  invariably  resulting. 

Differentiate  broncho=pneumonia  and  incipient  phthisis. 

This  is  very  frequently  difficult,  incipient  phthisis  often 
occurring  as  a  localized  broncho-pneumonia.  Broncho-pneu- 
monia follows  an  acute  bronchitis,  making  itself  known  by  a 
rise  in  temperature  over  103°  F.,  by  an  increase  in  the  respi- 
ratory and  pulse  rate,  the  pulse  commonly  running  from  120- 
160  per  minute,  while  the  respiratory  rate  may  be  from  40-80 
per  minute.  Broncho-pneumonia  occurs  at  the  extremes  of 
age.     The  physical  signs  of  well-developed  broncho-pneumonia 


DIAGNOSIS  AND  PRACTICE.  497 

are,  upon  inspection,  an  increased  respiratory  rate;  on  palpa- 
tion, increased  vocal  fremitus  in  areas  over  both  lungs;  upon 
percussion,  localized  areas  of  dulness  over  both  lungs  (more 
marked  posteriorly)  surrounded  by  a  tympanitic  area;  on 
auscultation,  broncho-vesicular  breathing  subcrepitant  rales 
mixed  with  large  and  small  mucous  rales.  The  physical  signs 
are  all  more  marked  posteriorly,  and  are  usually  well  marked 
at  the  bases. 

Incipient  phthisis  has  a  gradual  onset  with  loss  of  appetite, 
gastric  disturbance,  slight  evening  rise  of  temperature  (100° 
or  thereabouts),  anemia  and  general  malaise.  There  is,  as  a 
rule,  slight  cough  with  scanty  expectoration  (the  tubercle 
bacillus  may  be  found  in  the  expectorated  material).  Occa- 
sionally there  is  slight  hemoptysis  or  the  sputum  may  be  blood- 
tinged;  there  is  a  progressive  loss  of  weight.  The  physical 
signs  relate  principally  to  the  apices.  There  is  a  slight  im- 
pairment of  resonance  at  one  or  both  apices  on  percussion, 
and  upon  auscultation  there  may  be  heard  slight  friction 
sounds,  harsh  breathing  and  some  fine  moist  rales. 

What  are  the  diagnostic  signs  of  retro^pharyngeal 
abscess? 

This  may  follow  the  infectious  fevers,  such  as  scarlet  fever 
or  diphtheria,  usually  in  young  children,  occasionally  due  to 
caries  of  bone.  There  is  pain  on  swallowing  (dysphagia), 
difficulty  in  breathing,  occasionally  hoarseness,  cough  and 
stiffness  of  the  neck.  Upon  examination  of  the  throat  by 
inspection  and  palpation  there  is  discovered  a  fluctuating 
tumor  which  projects  from  the  posterior  wall  of  the  pharynx. 

Differentiate  tonic  and  clonic  spasms. 

A  tonic  spa.sm  is  a  continuous  spasm;  a  clonic  spasm  is  an 
interrupted  one  with  contraction  and  relaxation. 

Describe  the  symptoms  of  a  case  of  apoplexy  due  to 
cerebral  hemorrhage. 

Prodromes  may  precede  the  attack,  such  as  nausea,  vomit- 
ing, vertigo.     As  a  rule,  the  attack  comes  on  suddenly,  the 
32 


498  DIAGNOSIS  AND  PRACTICE. 

patient  becoming  comatose.  The  fade  is  flushed  or  pale.  There 
is  stertorous  breathing,  occasionally  of  the  Cheyne-Stokes 
type.  There  is  conjugate  deviation  of  the  head  and  eyes;  the 
pupils  are  irregular,  and  there  is  evidence  of  hemiplegia.  The 
pulse  is  slow  and  of  high  tension. 

Differentiate  acute  bronchitis  from  lobar  pneumonia. 

In  acute  bronchitis  there  is  cough,  at  first  without,  later 
with  mucopurulent  expectoration;  subfebrile  temperature, 
and  slight  pain  under  the  sternum.  There  are  no  changes 
from  the  normal  on  percussion,  but  upon  auscultation  there 
are  at  first  dry  rales,  followed  by  moist  rales  on  both  sides. 
Lobar  pneumonia  is  characterized  by  sudden  onset,  with 
marked  chill,  high  temperature,  ' '  stitches  in  the  side, ' '  cough, 
a  sputum  which  is  very  tenacious  and  often  rusty ;  full  pulse 
at  first,  later  becoming  rapid.  The  physical  signs  are  quite 
characteristic.  There  is,  in  the  first  stage,  the  crepitant  rale, 
in  the  second  stage  dulness  on  percussion  with  bronchial 
breathing  and,  in  the  last  stage,  "  crepitus  redux."  This  is. 
a  unilatei'al  process. 

Differentiate  hemoptysis  and  hematemesis. 

Hemoptysis.  Hematemesis. 

Blood    is  bright    red    frothy;  often      Blood    is    dark,    clotted    and     often 

coughed  up.  mixed  with  food;  is  vomited.  Stool* 

No  nausea.  niay  be  tarry;  nausea  great. 

Alkaline  in  reaction.  Acid  in  reaction. 

Containing  air  bubbles.  Air  bubbles  absent. 
Tubercle  bacilli  may  be  present  in  the      No  tubercle  bacilli  in  blood. 

blood. 

Differentiate  rheumatism  from  gout. 

Gout  occurs  suddenly  and  shows  a  special  preference  for 
the  smaller  joints,  especially  the  great  toe.  Rheumatism 
comes  on  more  gradually  and  attacks  principally  the  large 
joints.  The  appearance  of  the  joint  in  gout  is  swollen,  glossy, 
tense  and  bluish.  There  is  less  sweating  and  less  fever  than 
in    rheumatism ;    gastric   and    nervous   symptoms    are   never 


DIAGNOSIS  AND  PRACTICE.  499 

prominent.     Implication  of  the  membranes  of  the  heart  in 
gout  is  decidedly  less  frequent  than  in  rheumatism. 

Differentiate  intestinal  colic,  uterine  colic  and  renal 
colic. 

Intestinal  Colic. — Diffuse  pain,  which  may  be  localized, 
very  severe  in  character ;  usually  of  sudden  onset,  relieved  by 
pressure ;  lasting,  as  a  rule,  a  few  hours.  A  free  discharge  of 
riatus  relieves  the  attack. 

Uterine  Colic. — The  pain  is  in  the  pelvis,  there  is  some  his- 
tory of  uterine  discharge  and  disease. 

Renal  Colic. — The  pain  starts  from  the  region  of  the  kidney, 
shooting  down  the  ureter.  There  is  retraction  of  the  testicle ; 
often  nausea  and  sometimes  vomiting. 

Give  the  physical  signs  of  the  most  usual  valvular  lesion 
of  the  heart. 

Mitral  insufficiency  is  the  most  common  valvular  lesion  of 
the  heart.  The  physical  sign  is  a  murmur  at  the  apex,  systolic 
in  time  and  transmitted  to  the  left  axilla  and  the  angle  of  the 
scapula,  the  pulmonic  second  sound  being  always  accentuated. 

Differentiate  pleurisy  and  pneumonia. 

In  pleurisy  there  is  a  friction  sound  heard  commonly  both 
in  inspiration  and  expiration;  fever  is  slight,  there  is  marked 
pain  in  breathing.  There  may  be  slight  cough.  In  the  first 
stage  of  pneumonia  there  is  a  pleurisy,  especially  when  the 
inflammatory  exudate  reaches  the  periphery  of  the  lung. 
There  is  high  fever,  which  is  preceded  by  a  marked  chill, 
cough,  rusty  sputum  and  the  physical  signs  (crepitant  rale, 
dulne.ss  on  percussion,  bronchial  breathing  and  crepitus 
redux). 

What  conditions  might  cause  alvine  discharge  contain- 
ing fat? 

In  obstructive  jaundice  fatty  stools  are  sometimes  noted; 
they  occur  occasionally  in  overfed  infants.  Fatty  stools  are 
often  indicative  of  disease  of  the  pancreas,  such  as  cancer  or 
paiicrciitic  calculi. 


500  DIAGNOSIS  AND  PRACTICE. 

Give  the  characteristic  symptoms  of  purpura  hemor= 
rhagica. 

Hemorrhages  from  the  mucous  membranes  and  extravasa- 
tion in  the  cutaneous  surfaces;  great  weakness,  anemia  due  to 
loss  of  blood.     Fever  is  present,  as  a  rule. 

What  conditions  increase  the  amount  of  uric  acid  voided 
with  the  urine? 

Increased  by  diet  (fat  and  sugar),  muscular  exercise.  In 
the  acute  fevers  (pneumonia  and  rheumatic  fever),  in  leuke- 
mia and  in  disease  of  the  spleen  generally ;  in  diabetes  and  in 
lithemia.  It  is  decreased  in  amount  under  strict  milk  diet,  in 
anemia,  chronic  lead-poisoning  and  chronic  interstitial  neph- 
ritis. 

Differentiate  thrombosis  and  embolism. 

Thrombosis. — Prodromes  are  common,  drowsiness  and  head- 
ache, the  onset  of  the  attack  is  insidious.  Hemiplegia  gradual 
in  onset.     Ocular  and  other  nerve  palsies. 

Embolism. — Loss  of  consciousness  rapid,  hemiplegia  and 
disturbances  of  the  pulse  and  respiration.  Embolism  is  moi'e 
frequent  in  the  left  side  of  the  brain,  hence  valvular  disesise 
favors  embolism. 

What  diseases  are  liable  to  occur  in  the  right  inguinal 
region? 

Appendicitis,  floating  kidney,  disease  of  the  liver  and  of  the 
bladder. 

Distinguish  between  the  terms  illusion,  delusion  and 
hallucination  as  used  in  diagnosis. 

An  illusion  is  a  wrong  conception  of  an  object  which  really 
exists.  A  delusion  is  an  absurd  and  unfounded  belief.  A 
hallucination  is  a  sense  perception  without  a  physical  basis. 

Give  the  physical  and  rational  signs  of  pericarditis  be- 
fore and  after  effusion. 

There  is  slight  fever,  marked  pain  in  the  precordial  region, 
dyspnea  and  irregular,  usually  quickened,  pulse.     There  is 


DIAGNOSIS  AND  PRACTICE.  501 

pericardial  friction  on  auscultation.  When  effusion  occurs 
the  friction  disappears ;  there  is  dulness  in  the  precordial  area, 
the  base  of  dulness  being  at  the  apex  of  the  heart,  quite  the 
reverse  from  the  usual  condition,  the  apical  sound  being 
muffled  and  indistinct. 

Define  vocal  fremitus  and  state  its  significance  in  pul- 
monary disease. 

Vocal  fremitus  means  the  vibrations  of  the  voice  which 
are  transmitted  to  the  chest  wall.  Tnese  are  conducted  from 
the  larynx  by  the  trachea  and  bronchi  to  the  smaller  tubes 
within  the  lungs,  and  thence  through  the  lung  tissue  to  the 
surface.  Vocal  fremitus  is  increased  by  consolidated  lung 
tissue;  it  is  increased  from  an  empty  pulmonary  cavity  super- 
ficially situated,  and  is  diminished  or  lost  on  accumulation  of 
tiuid  in  the  pleural  cavity. 

Differentiate  between  sunstroke  (coup  de  soleil)  and 
apoplexy. 

In  sunstroke  there  is  the  history  of  exposure  to  the  sun. 
The  temperature  is  very  high,  105°-115°  or  over,  but  no  evi- 
dence of  hemiplegia.  In  apoplexy  there  is  conjugate  devia- 
tion of  the  head  and  eyes,  hemiplegia,  irregular  pupils,  never 
so  high  a  temperature,  and  full,  bounding  pulse. 

What  casts  are  frequently  found  in  albuminous  urine 
and  what  do  they  denote? 

Hyaline,  granular,  waxy,  epithelial  and  blood  casts.  Hyaline 
casts  probably  result  from  the  exudation  or  secretion  of  a 
material  from  the  epithelial  cells  lining  the  tubules.  They 
are  sometimes  found  in  healthy  individuals.  Granular  casts 
indicate  nephritis.  Epithelial  casts  are  always  indicative  of 
a  renal  lesion.  Blood  casts  are  found  in  acute  parenchyma- 
tous nephritis  or  in  a  condition  in  which  the  renal  tubules 
become  filled  with  red  blood  corpuscles.  Waxy  or  amyloid 
casts  occur  in  chronic  interstitial  nephritis  and  chronic  sup- 
purative processes. 


502  DIAGNOSIS  AND  PRACTICE. 

Of  what  import  is  the  spleen  in  the  diagnosis  of  febrile 
conditions?    Give  the  topography  of  the  spleen. 

As  a  rule,  the  spleen  is  enlarged  in  all  febrile  conditions. 
The  spleen  extends  from  the  ninth  rib  to  the  margin  of  the 
twelfth  rib  in  the  midaxillary  line  of  the  left  side. 

Differentiate  the  crepitant  rales  and  the  subcrepitant 
rales  and  give  the  clinical  significance  of  each. 

The  crepitant  rale  is  a  fine  moist  rale  and  is  heard  only  at 
the  end  of  inspiration.  It  is  found  in  the  vesicular  structure 
of  the  lung.  The  subcrepitant  rale  is  also  a  fine  moist  rale, 
somewhat  coarser  than  the  crepitant  rale,  found  in  the  finer 
bronchi  and  heard  both  in  inspiration  and  in  expiration. 
The  crepitant  rale  is  heard  in  croupous  pneumonia,  broncho- 
pneumonia, hemorrhage,  pulmonary  infarcts,  edema  of  the 
lung  and  sometimes  in  tuberculosis.  The  subcrepitant  I'ale 
is  heard  in  congestion  and  edema  of  the  lungs,  in  hemorrhage 
or  in  any  condition  in  which  fluid  is  present  in  the  finer  bron- 
chi ;  in  pulmonary  tuberculosis,  in  the  third  stage  of  croupous 
pneumonia  and  in  broncho-pneumonia. 

What  are  the  manifestations  of  hereditary  syphilis? 

The  child  at  birth  is  very  feeble,  and  the  eruption  may  be 
present;  the  child  snuffles,  the  mouth  is  fissured,  and  the  lips 
are  ulcerated.  Liver  and  spleen  are  enlarged,  and  bone  symp- 
toms are  prominent.  If  the  symptoms  do  not  appear  at  birth, 
they  will  appear  at  or  about  the  third  month.  There  is  then 
nasal  catarrh,  with  a  seropurulent  discharge.  Necrosis  of 
bone  is  rapid,  and  the  nose  undergoes  a  characteristic  de- 
formity. Lesions  of  the  skin  also  appear.  When  the  teeth 
appear  they  are  notched  (Hutchinson's  teeth"). 

Make  a  diagnosis  of  aneurysm  of  the  descending  aorta. 

There  is  marked  pain,  especially  in  the  back,  and  a  large 
tumor  may  appear  posteriorly  in  the  scapular  region.  Para- 
plegia may  occur  from  pressure  on  the  cord,  dysphagia  from 
pressure  on  the  esophagus,  and  pulmonary  symptoms  from 
pressure  on  the   left  bronchus.     There  are,  besides,  all  the 


DIAGNOSIS  AND  PRACTICE.  503 

physical  signs  of  aneurysm  in  any  other  locality,  such  as  ex- 
pansible pulsation,  tumor,  bruit  and  thrill. 

Make  a  differential  diagnosis  of  pleuritic  and  pericardial 
effusion. 

If  the  pericardial  effusion  be  very  great,  it  may  much 
resemble  a  left-sided  pleural  effusion.  In  pericardial  effusion, 
however,  there  is  pulmonary  resonance  at  the  base,  Skodaic 
resonance  in  the  axilla,  and  the  heart  is  not  displaced  to  the 
right  of  the  sternum.  The  dyspnea  is  greater  in  pericarditis 
with  effusion,  and  the  paradoxical  pulse  may  be  present.  An 
antecedent  history  of  rheumatic  fever  may  help  the  diagnosis 
and  favor  pericarditis. 

Describe  the  treatment  of  hay  fever. 

A  change  of  residence  before  the  annual  attack  is  the  only 
prophylaxis;  a  correction  of  the  neurotic  and  gouty  tendency 
of  the  individual  should  be  attempted.  A  spray  to  keep  the 
nasal  passages  clean  is  important.  A  weak  solution  of  cocaine 
for  this  purpose  is  valuable.  Suprarenal  extract  appears  to 
give  the  best  results  both  locallj^  and  internally. 

Define  epidemic  parotitis.  What  complications  may 
arise  in  the  course  of  this  disease? 

There  is  abrupt  development  of  fever  and  an  enlarged  par- 
otid gland  on  one  side.  Inflammatoiy  edema  of  the  surround- 
ing tissue  is  common,  the  ear  may  be  pushed  upward.  The 
mouth  is  displaced  and  the  face  disfigured.  The  fever  is 
usualy  about  102°.  In  some  cases  the  opposite  gland  becomes 
affected  after  a  few  days.  Suppuration  does  not  occur. 
Occasionally  other  glands,  such  as  the  testicles,  ovaries  and 
mammary  glands,  are  affected. 

Define  chlorosis. 

Chlorosis  is  a  form  of  primary  anemia,  affecting  chiefly 
females  at  the  time  of  puberty,  and  characterized  by  marked 
diminution  of  the  hemoglobin. 


504  DIAGNOSIS  AND  PRACTICE. 

Name  some  conditions  which  materially  affect  the  tem- 
perature in  typhoid  fever. 

Cold  baths,  antipyretics,  sudden  perforation,  hemorrhage, 
abortion  or  collapse  of  circulation  will  cause  a  sudden  drop: 
broncho-pneumonia,  abscess,  peritonitis,  or  suppuration,  will 
cause  irregularity,  and  delay  lysis.  Post  anemic  fever  or  un- 
healed ulcers  may  prolong  it  indefinitely. 

Name  three  conditions  giving  (a)  lymphocytosis,  (b) 
leucocytosis. 

(a)  Malaria,  syphilis,  whooping  cough. 

(b)  Lobar  pneumonia,  rheumatism,  diphtheria. 

Differentiate  (a)  typhoid  fever,  (b)  malaria,  (c)  sep- 
itcemia. 

(a)  Onset  insidious,  fever  is  step-like  in  ascent  and  con- 
tinuous, headache  and  apathy  or  delirium,  pulse  slower  in  pro- 
portion to  fever,  rose-colored  spots,  leucopenia,  Widal  test  or 
blood  culture  positive,  diazo  urine  reaction,  tendency  to  in- 
testinal complications,  decline  by  lysis. 

(b)  Onset  abrupt.  Chills,  fever  and  sweating  at  regular 
periods,  icteroid  skin,  parasite  in  blood.  Therapeutic  test  of 
quinine  relieves  condition.     Declines  by  crisis. 

(c)  History  or  evidence  of  traumatic  lesion.  Glandular  en- 
largement. Rapid  onset,  high  continuous  fever.  Marked 
nervous  symptoms.     Leucocytosis.     Declines  by  lysis. 

What  are  the  symptoms  and  physical  signs  present  in 
acute  pericarditis  with  effusion? 

Precordial  pain  or  distress,  dyspnea,  palpitation,  prostra- 
tion, irregular  fever  and  pulse,  gastro-intestinal  disturbances 
and  mental  unrest.  Displaced,  absent,  or  feeble  apex-beat, 
collapsible  pulse  on  deep  inspiration.  Triangular  dulness 
with  base  downward  at  7th  rib,  to  left  axilla  and  right  of 
sternum,  and  upward  to  2nd  or  3rd  left  rib,  movable  on  change 
of  posture.  Apical  heart  sounds  muffled  and  indistinct. 
Second  sounds  at  base  are  relatively  sharp.  Friction  rub 
present  at  root  of  great  vessels. 


DIAGNOSIS  AND  PRACTICE.  505 

What  are  the  symptoms  of  gastric  ulcer? 

Pain  in  epigastrium,  increased  by  taking  food,  relieved  by 
vomiting  or  end  of  digestion.  Hematemesis  in  50%  of  eases. 
Symptomatic  anemia.  Neurasthenia.  Occult  blood  test  posi- 
tive.    Vomiting  an  hour  or  two  after  meals. 

Describe  the  course,  giving  the  symptoms  and  physical 
signs  of  an  acute  lobar  pneumonia. 

Onset  sudden  with  rigor,  prostration,  vomiting,  and  sharp 
pleuritic  pain.  Temperature  rises  abruptly.  Remains  high 
and  continuous,  and  drops  by  crisis  from  fifth  to  ninth  day. 
Respirations  jerky  and  increased,  with  characteristic  grunt. 
Hacking  cough.  Herpes  facialis.  Mahogany  blush.  Rusty 
and  tenacious  sputum.  Leucocytosis.  Anxious  mentality. 
Physical  signs  of  first  stage :  decreased  vesicular  breathing  on 
affected  side,  with  pleuritic  rub  and  crepitant  rales  at  end 
of  inspiration.  Second  stage :  dulness,  increased  tactile  fremi- 
tus; full,  bounding  but  easily  compressible  pulse,  bronchial 
breathing,  and  a  sharply  accented  second  pulmonic  heart 
sound.  Third  stage,  presence  of  numerous  moist  redux  crepi- 
tant rales,  with  other  signs  returning  to  normal. 

Describe  the  characteristic  symptoms  and  course  of  a 
case  of  scarlet  fever. 

Sudden  onset,  with  chill  or  convulsion.  Severe  vomiting. 
Angina.  Tonsillar  exudate.  Glands  of  neck  swollen  and  very 
painful.  High  temperature.  Hard,  rapid,  wiry  pulse.  Leu- 
cocytosis. Diffuse  punctiform  erythema  appears  on  fii*st  or 
second  day,  fades  after  first  week.  Desquamation  in  scales 
lasting  from  second  to  sixth  week.  Tongue  thick  and  coated, 
becoming  of  strawberry  appearance  about  third  day.  Ten- 
dency to  nephritis  and  otitis  media  during  the  later  stages. 

Describe  the  symptoms  and  treatment  of  a  case  of  peri- 
tonsillar abscess  (Quinsy). 

Onset  sudden  with  chills,  moderate  fever,  prostration,  head- 
ache, dyspliagiii,  nninicd  voioo.  slimy  tongue,  thirst,  frequent 


506  DIAGNOSIS  AND  PRACTICE. 

desire  to  swallow,  dull  throbbing  pain,  usually  unilateral  ear- 
ache and  dulled  hearing,  glandular  swelling,  lasting  three  to 
five  days,  when  it  ruptures  or  absorbs.  Treatment  supportive. 
Narcotics  to  relieve  pain.  Cold  or  heat  locally.  Incision 
if  abscess  points.     Hematinics  later. 

What  are  the  symptoms  of  intestinal  perforation  in 
typhoid  fever? 

Drop  in  temperature,  restlessness,  development  of  leucocy- 
tosis,  acute  lancinating  abdominal  pain,  with  swelling,  rigid- 
ity, tenderness,  and  collapse :  pulse  rapid  and  low  tension, 
pinched  facies.     Vomiting,  later  becoming  fecal  in  character. 

What  are  the  somatic  signs  of  acquired  syphilis? 

Primary  :  chancre  and  adenitis. 

Secondary :  Maculo-papular  rash,  mucous  patches  in  mouth, 
falling  of  hail's,  bone  pains,  anemia. 

Tertiary:  Gummata,  ulcers,  rupia  and  other  skin  lesions. 
Later,  endarteritis,  and  sclerosis  of  central  nei'vous  system. 

What  is  Duke's  disease,  or  the  so=caIled  Fourth  disease? 

An  acute  infectious  process  having  some  features  common 
to  scarlet  fever  and  to  German  measles,  but  not  a  clear-cut 
picture  of  either.  1.  Scarlet  fever,  2.  Rubeola,  3.  Rotheln, 
4.  Duke's  disease. 

What  are  some  of  the  serious  complications  which  may 
result  from  an  abscess  in  the  middle  ear? 

Caries  or  necrosis  of  temporal  bone :  mastoiditis,  meningitis, 
brain  abscess,  thrombosis  of  the  lateral  sinus,  cholesteatomata, 
necrosis  of  ossicles,  chronic  otorrhea,  facial  palsy,  polypi  and 
boils. 

What  are  the  symptoms  and  what  is  the  treatment  of 
poisoning  by  acetanilid? 

Prostration,  lividity,  marked  cyanosis,  subnormal  temper- 
ature, soft,  low-tensioned  pulse,  shallow  respiration,  sweat- 
ing, muscular  weakness,  dizziness  or  vertigo  on  exertion, 
methemoglobjnuria,  mental  apathy  or  mild  delirium. 


DIAGNOSIS  AND  PRACTICE.  507 

Treatment.  Ammonia,  strychnine,  belladonna,  coffee,  ex- 
ternal heat,  oxygen,  artificial  respiration. 

Describe  the  treatment  of  a  case  of  acute  rheumatic 
endocarditis. 

Absolute  rest  of  body  and  mind.  Doreal  decubitus.  Ice 
bags  or  sinapisms  locally.  Aconite  to  reduce  rate  and  force 
of  heart.  Alkalies  or  sodium  salicylate.  Potassium  iodide 
later.     Warm  equable  clothing.     Restrict  physical  exertion. 

Describe  the  symptoms  and  treatment  of  a  case  of  fecal 
impaction. 

Occurs  in  chronic  constipation,  the  aged,  hysterical,  or  in- 
sane persons.  ]\Iore  common  in  females.  Occurs  at  flexures. 
Mass  may  be  palpated.  Localized  pain  and  tenderness.  Con- 
stipation with  watery  diarrhea.  Nausea  and  vomiting. 
Colic.  Irrigation  brings  away  scybalous  masses,  or  partial 
mould  of  gut  outline.  Systemic  symptoms  of  collapse  if  acute. 
Treatment :  Soften  and  loosen  fecal  mass  by  oil  per  oram,  or 
injection.  If  in  rectum  break  up  with  spoon  or  fingers.  Sup- 
portive measures.  Stimulation.  Restricted  diet.  Laparo- 
tomy if  not  relieved  in  24  hours. 

Outline  the  management  of  a  case  of  chronic  nephritis. 

Warm  equable  climate,  woolen  underwear,  remove  from  all 
cares,  guarded  exercise,  interdict  all  alcohol,  restrict  proteids, 
attend  to  elimination  by  skin  and  bowels,  bathing.  Combat 
anemia  with  iron.  Diuretics  when  necessary.  Symptomatic 
treatment  for  complications. 

Outline  the  treatment  of  a  case  of  diphtheria  by  the  use 
of  antitoxin,  and  state  the  principles  upon  which  the  treat- 
ment with  antitoxin  is  based. 

Administer  hypodermatically  under  strict  asepsis,  initial 
dose  of  4000  to  8000  units,  and  repeat  every  twelve  hours 
until  good  effects  are  noted.  It  is  held  that  an  antitoxin  con- 
tains substances  that  can  neutralize  toxines  which  are  de- 
veloped by  bacterial  infection  of  the  body,  thus  reinforcing 


508  DIAGNOSIS  AND  PRACTICE. 

the  normal  power  of  the  human  blood  to  combat  the  poison- 
ous effects  of  the  toxins  on  the  body. 

How  would  you  treat  a  case  of  strychnine  poisoning? 

First  give  tannic  acid  in  any  form,  as  in  tea,  etc.,  followed 
by  lavage  of  stomach.  Chloral  and  bromide  by  mouth  or 
rectum.  Chloroform  inhalations  for  spasms  until  the  chloral 
action  is  established.  Frequent  catheterization  of  bladder. 
Croton  oil  as  purgative.     Complete  isolation  and  rest. 

Name  the  chief  classes  of  drugs  used  as  diuretics,  and 
state  the  different  classes  of  cases  in  which  they  are  used. 

Those  which  act  directly  by  raising  blood  pressure  as  digi- 
talis and  belladonna.  Those  which  stimulate  the  secretory 
cells  of  the  kidney,  as  the  alkaline  salts  and  balsams,  potassium 
citrate  or  bi-tartrate,  copaiba  and  cubebs.  Scoparius  and 
caffeine  combine  both  effects.  The  potash  salts  reduce  the 
acidity  and  increase  solids.  Digitalis  increases  the  watery 
elements  of  the  urine,  and  is  used  in  venous  stasis,  dropsy,  and 
low  blood  pressure. 

Name  some  of  the  indications  and  contra=indications  to 
the  use  of  digitalis  as  a  cardiac  stimulant. 

Indications  for  use:  in  failure  of  compensation  of  valvular 
heart  disease:  in  lowered  arterial  tension,  as  shock,  collapse, 
hemorrhage,  injuries,  certain  stages  of  nephritis,  and  sudden 
dilatation  of  the  heart. 

Contra-indications :  High  tension  of  arteriosclerosis  or 
atheroma,  advanced  myocardial  degeneration,  or  if,  after  us- 
ing for  a  time,  the  heart's  action  becomes  irregular. 

What  plants  contain  caffein?  Into  what  official  com- 
pounds does  caffein  enter? 

Dried  leaves  of  Thea  sinensis  and  Camellia  thea;  dried  seeds 
of  Coffea  arabica:  also  prepared  synthetically. 

1.  Cnffeina  citrata,  gr.  i-v. 

2.  Caffeina  citrata  efffrvescens,  3i-iii. 


DIAGNOSIS  AND  PRACTICE.  509 

Name  the  official  preparations  of  belladonna  leaves  and 
root. 

Leaves:  Pilulae  podophylli  belladonnae  et  capsici. 
Pilulae  laxaiivae  compositae. 
Extractum  belladonnae  foliorum,  gr.  ^g— 1. 
Tinctura  "  "  n^  5-20. 

Unguentum        '•  " 

Emplastrum       "  " 

The  dried  leaves  must  yield  not  less  than  0.35%,  and  the  root 
not  less  than  0.5%  of  its  alkaloids. 

Root:  Fluidextractum  belladonnae  radicis,  ^,  I'o-H. 
Linimentum  belladonnae. 

State  how  the  following  drugs  may  be  best  adminis= 
tered.  (a)  Argenti  nitras,  (b)  Oleum  terebinthinae,  (c) 
Oleoresina  aspidii. 

(a)  In  pill,  capsule,  or  mucilage  of  acacia,  (b)  In  muci- 
lage, capsule,  or  on  lump  sugar,  (c)  In  capsule,  milk  or 
mucilage. 

What  are  the  symptoms  of  acute  carbolic  acid  poisoning, 
and  how  would  you  treat  it? 

May  occur  from  local  application,  as  well  as  internal  use. 
Local  tingling  or  numbness.  Sloughing  or  gangrene.  Dys- 
phagia, nausea,  vomiting,  pallor,  shock,  delirium  or  stupor. 
Scanty  smoky  urine.  Odor  on  breath  and  urine.  Glazed 
and  shriveled  mucous  membrane. 

Physiological  antidote  —  sulphate  of  sodium  or  mag- 
nesium, dilute  sulphuric  acid,  or  vinegar.  Alcohol  in  any 
form  freely.  Carefully  empty  stomach.  Frequent  catheter- 
ization. Strychnine,  atropine,  camphor  oil,  hypodermatically. 
Avoid  stomach  pump. 

What  is  the  dose  of  chloral  hydrate?  Give  some  of  the 
indications  for  its  use. 

Dose  v-xx  grs.  Indicated  in  extreme  nervousness  or  in- 
somnia without  pain,  as  in  alcoholism.     Acts  locally  as  an 


510  DIAGNOSIS  AND  PRACTICE. 

anesthetic,  as  in  pniritis.     Is  useful  in  controlling  convulsions 
from  whatever  cause. 

Contra-indicated  in  shock,  collapse  or  myocardial  degener- 
ation. Is  useful  as  physiological  antidote  in  strychnine 
poisoning. 

What  effect  has  each  of  the  following  drugs  upon  the 
bowels,  and  how  do  they  produce  their  several  actions: 
(a)  opium,  (b)  cascara  sagrada,  (c)  magnesium  sulphate. 

(a)  Small  doses  produce  constipation  by  inhibition  of  the 
splanchnic.  Excessive  doses  may  paralyze,  and  cause 
diarrhea, 

(b)  Stimulates  intestinal  glands  and  increases  secretions 
and  peristalsis. 

(c)  Extracts  water  from  the  intestinal  bloodvessels  by  in- 
creased osmosis. 

Name  the  indications  and  contra=indications  to  the  use 
of  aconite. 

In  all  conditions  of  extreme  arterial  hypertension,  as  sthenic 
fevers,  arterio-sclerosis,  acute  inflammations  as  tonsillitis,  per- 
nicious vomiting,  early  stage  of  cerebral  apoplexy,  nervous 
palpitation. 

Contra-indicated  in  adynamic  conditions,  as  myocardial  de- 
generation, dilatation  or  long-continued  toxic  processes,  as 
typhoid  fever  or  tuberculosis. 

What  should  be  the  alkaloidai  strength  of  (a)  gum 
opium,  (b)  powdered  opium?  Which  form  is  used  in  of= 
ficial  preparations? 

(a)  9%  of  morphine  crystals. 

(b)  Not  less  than  12%,  nor  more  than  12i/^%  of  morphine 
crystals. 

The  granulated  or  deodorized  opium  is  used  in  official  pre- 
parations, except  in  the  pill  and  in  the  camphorated  tincture. 

Give  the  adult  dose  of  five  tinctures  and  five  fluid  ex- 
tracts.      Also    of     strychnia,    morphine,    atropina,    phos= 


DIAGNOSIS  AND  PRACTICE.  511 

phorus,  arsenic  trioxide,  aloes,   magnesium  sulphate,  and 
sodium  salicylate. 

Tinctura  cannabis  indicae,  n^^  x. 
"         cinchonae,  3  j. 
"         digitalis,.  ^,  xv. 
"         hyoscyami,  n\^  xxx. 
"         veratri,  rr^  xv. 
Fluidextractum  colchici  seminis,  n^  iii. 
"  ergotae,  n\^  xxx. 

"  gelsemii,  rri  1. 

"  lobeliae,  n^^  viii. 

"  rhei,  ^,  xv. 

Strychnine,  gr.  J^. 
Morphine,  gr.  i. 
Atropina,  gr.  yi^. 
Phosphoru?,  gr.  j^j. 
Arsenic  trioxide,  gr.  3^. 
Aloes,  gr.  xv. 

Magnesium  sulphate,  si-si. 
Sodium  salicylate,  gr.  xv. 


HYGIENE. 


What  is  Hygiene? 

The  art  and  science  of  preserving  and  improving  health, 
a.nd  the  prevention  of  disease. 

What  principal  hygienic  direction  should  be  given  a 
patient  suffering  from  tuberculosis? 

Always  expectorate  into  or  on  such  appliances  as  may, 
with  their  contents,  be  disinfected  or  burned.     Avoid  kissing. 

How  can  malarial  districts  be  made  healthy? 

Remove  moisture  from  the  locality  by  surface  or  sub-soil 
draining;  by  planting  trees  like  the  eucalyptus,  which  require 
much  water  for  their  growth ;  by  preventing  the  development 
of  the  mosquito  larvae,  through  the  action  of  petroleum  on 
water  surfaces. 

Differentiate  between  endemic,  epidemic  and  pandemic 
diseases. 

An  endemic  disease  is  one  constantly  present  in  a  com- 
munity. An  epidemic  disease  is  one  which  attacks  many 
people  at  the  same  time.  A  pandemic  disease  is  one  which 
spreads  rapidly  over  wide  areas. 

State  the  results  to  animal  life  of  the  combustion  of  fuel 
in  a  room  without  chimney  connection  or  other  ventilation. 

Carbon  monoxide  poisoning,  suffocation  due  to  excessive 
quantity  of  carbon  dioxide  and  diminished  amount  of  oxygen; 
a  systemic  poisoning  due  to  breathing  products  which  are 
the  result  of  partial  combustion,  modified  by  the  excretions 
thrown  off  in  exhalations. 

33  (  513  ) 


514  HYGIENE. 

What  is  the  best  method  of  disposing  of  the  bodies  of 
those  who  have  died  of  yellow  fever? 

Cremate  such  bodies. 

What  is  meant  by  natural  and  acquired  immunity  from 
disease?    Give  an  example  of  each. 

By  natural  immunity  we  mean  "that  inherited  trait  from 
immune  ancestors  which  enables  an  organism  to  resist  the 
attacks  of  bacteria  and  their  toxic  secretions."  Thus,  as  a 
rule,  the  negro  race  does  not  contract  yellow  fever.  By  ac- 
quired immunity  we  understand  that  through  a  previous 
attack  of  an  infectious  disease,  or  by  inoculation  with  an 
attenuated  virus  of  that  disease,  the  blood  of  the  person 
undergoes  such  changes  as  to  present  a  non-fertile  soil  to  the 
organism  to  whose  presence  the  disease  is  due.  Example, 
vaccination  m  preventing  small-pox. 

What  are  the  principal  measures  which  you  would 
employ  for  the  prevention  of  the  spread  of  infectious 
diseases? 

Isolate  the  patient  and  attendants;  disinfect  all  substances 
removed  from  patient's  room  before  their  removal;  establish 
the  purity  of  water  and  food  supplies ;  disinfect  the  room  and 
contents  after  patient's  removal,  and  observe  a  precautionary 
quarantine. 

How  would  you  prepare  an  artificial  food  for  a  new= 
born  infant? 

Render  cow's  milk  as  alkaline  as  human  milk.  Dilute  with 
water  to  reduce  the  quantity  of  casein  to  what  it  would  be 
in  maternal  milk.  Fat  and  sugar  are  increased  by  the  addi- 
tion of  cream  and  sugar  of  milk.  To  one  pint  of  sterilized 
water  17%  drachms  of  pure  commercial  sugar  of  milk  are 
added' and  dissolved.  This  sugar  water  must  be  kept  in  a 
cool  place  and  not  be  alowed  to  sour.  When  feeding  time 
arrives  two  tablespoonfuls  of  cream,  one  of  milk,  two  of  lime 
water,  and  three  of  the  milk-sugar, water  are  mixed,  and  as 
soon  as  this  mixture  has  been  warmed  to  proper  temperature- 


HYGIENE.  515 

it  may  be  poured  into  a  bottle  and  the  food  is  ready  for  use. 
(FisHer.) 

What  are  the  properties  of  oleomargarin  compared  with 
butter  made  in  the  usual  way? 

Butter  fat  contains  nearly  8%  of  the  volatile  fats;  specific 
gra\aty  never  below  .909.8 ;  insoluble  fatty  acids  form  about 
88%  of  the  weight  of  butter  fat;  melting-point  of  fat  is 
between  86^  and  94'  F. ;  readily  and  completely  soluble  in 
ether. 

Oleomargin  fat  contains  about  1/0%  of  the  volatile  fats; 
specific  gravity  never  above  904.5 ;  insoluble  fatty  acids  form 
about  95%  of  the  total  weight;  melting-point  rarely  above 
82°  F. ;  less  soluble  in  ether  and  leaves  a  residue. 

State  the  value  of  public  baths  to  the  health  of  a  large 
city. 

They  give  facilities  to  the  poor  for  obtaining  personal  clean- 
liness, exerting  a  protective  influence  over  the  development 
and  spread  of  filth  diseases.  They  encourage  the  young  to 
learn  to  swim,  and  supply  an  excellent  form  of  exercise,  pro- 
moting growth  and  development.  When  properly  used  their 
effects  are  both  tonic  and  stimulating. 

What  is  sewer  gas?  How  does  the  inhalation  of  sewer 
gas  in  large  quantities  affect  the  system? 

Sewer  gas  is  a  mixture  of  a  number  of  gases,  among  which 
we  find  carbonic  acid  gas,  light  carburetted  hydrogen,  nitro- 
gen, hydrogen  sulphide,  ammonium  sulphide  with  fetid  or- 
ganic matter,  the  volatile  and  semi-volatile  results  of  animal 
and  vegetable  decomposition. 

Sewer  gas  gaining  entrance  to  house  or  room  may  exert  a 
depressing  influence  upon  the  occupants,  and  may  occasion 
vomiting,  purging,  severe  headache,  prostration,  and  through 
its  carriage  of  germs  cause  infectious  diseases..  Yet  sewer 
gas  per  se  is  sometimes  almost  innocuous.  A  chronic  form 
of  poisoning  from  sever  gas  gives  rise  to  pallor,  languor, 
frequent  headaches,  los.s  of  appetite,  diarrhoea,  generally  im- 
paired health  and  anemia. 


516  HYGIENE. 

Is  green  wall=paper  objectionable;  if  so,  why? 

Sometimes,  because  its  color  may  be  clue  to  a  compound  of 
copper  and  arsenic,  which  after  becoming  damp  dries,  and  is 
rubbed  or  blown  from  the  walls,  producing  acute  or,  more 
often,  chronic  forms  of  arsenical  poisoning  as  well  as  me- 
chanical irritation  of  fauces,  conjunctiva,  etc. 

Contrast  the  incubative  stages  of  variola  and  measles. 

The  incubative  stage  of  variola  is  from  six  to  seven  days 
by  inoculation,  and  from  ten  to  fourteen  days  by  infection. 
In  measles  it  is  from  seven  to  ten  days  by  inoculation  and 
from  seven  to  twenty-one  days  by  infection. 

What  conditions  and  diseases  in  animals  render  their 
flesh  unfit  for  food? 

"The  flesh  of  all  animals  dead  of  internal  diseases,  or 
which  have  been  killed  while  suffering  from  such  diseases  or 
animal  killed  by  overdriving.  The  flesh  of  animals  with 
contagious  diseases  that  may  be  transmitted  to  man.  The 
flesh  of  animals  that  have  been  poisoned.  The  flesh  of  ani- 
mals with  severe  infectious  diseases,  as  pyemia,  etc.  Flesh 
containing  parasites  that  may  be  transmitted  to  men.  All 
putrid  flesh''   (Gerlach). 

Discuss  detached  wards  versus  many=storied  buildings 
for  a  public  hospital. 

Many  wards  in  one  building  render  the  maintaining  of  dis- 
cipline and  supervision  easier.  Quicker  service,  ease  of  com- 
muncation  and  greater  economy  of  administration  are  favored 
by  many  wards.  Many-storied  buildings  prevent  perfect  iso- 
lation and  ventilation,  render  diminished  supply  of  sunlight, 
lead  to  danger,  as  in  removal,  should  fire  occur;  so  that  the 
detached  ward  system  seems  preferable. 

Give  a  fair  average  death  rate  (a)  in  rural  districts,  (b) 
in  towns  of  from  5,000  to  20,000,  (c)  in  cities  of  over 
100,000  inhabitants. 

(a)  14,  (b)  17,  (c)  19  to  22  per  thousand. 


HYGIENE.  517 

Mention  five  preventable  diseases. 

Tuberculosis,  typhoid  fever,  cholera,  yellow  fever  and 
malaria. 

Give  the  special  hygiene  of  factories  in  which  women 
and  children  are  employed. 

Each  child  or  woman  should  be  allotted  sufficient  space  to 
supply  3,000  cubic  feet  of  fresh  air  an  hour  by  a  not  greater 
air  movement  than  that  which  would  change  the  air  three 
times  each  hour.  The  temperature  should  be  kept  constant 
at  about  65  degrees  Fahr.  Means  should  be  employed  to 
quickly  remove  dust  or  offensive  and  dangerous  gases.  Per- 
sonal cleanliness  should  be  facilitated  by  properly  equipped 
wash-rooms.  The  water-closet  fixtures  should  be  ample  and 
of  proper  construction.  An  infirmary  should  be  provided 
for  immediate  treatment  of  injuries  and  suddenly  occurring 
illnesses. 

In  the  selection  of  a  site  for  a  dwelling  what  is  the  best 
sanitary  soil,  sub=soil  and  topography? 

A  light,  dry  soil,  as  of  gravel  or  sand,  that  contains  no 
absorbed  filth  or  sewage,  with  a  nearly  constant  level  of 
ground  water,  avoiding  clay  or  impermeable  material  both  in 
the  soil  and  in  the  sub-soil.  The  location  should  not  be  in 
low-lying  districts,  nor  in  localities  which  from  the  geolog- 
ical formation  act  as  collectors  of  underground  water.  The 
house  should  not  be  placed  on  the  top  of  an  elevation  where 
it  would  be  exposed  to  strong  winds.  All  other  conditions 
being  favorable,  the  house  should  be  built  on  the  side  of  a 
hill  so  that  it  receives  a  maximum  supply  of  air  and  sun- 
light, and  in  cold  climates  preferably  with  a  southern  ex- 
posure. 

What  is  the  bubonic  plague?  What  steps  can  be  taken 
to  limit  or  extinguish  such  a  scourge? 

It  is  an  acute  contagious  and  infectious  disease  favored  by 
filthy  surroundings  and  at  times  occurring  epidemically.  It 
is   due    to    a   specific   micro-organism    and    is    characterized, 


518  HYGIENE. 

among  other  symptoms,  by  glandular  swelling  terminating  in 
abscess.  Prevention  depends  upon  isolation  of  the  sick,  de- 
struction of  vermin  and  rodents,  thorough  disinfection  of  the 
clothing  and  surroundings  of  the  patient,  the  avoid- 
ance of  overcrowding  and  filth,  and  the  institution  of  rigid 
quarantine  to  prevent  its  dissemination. 

Name  the  principal  adulterations  of  wine. 

"Water,  coloring  agents  (logwood,  red  beets,  coal-tar  prod- 
ucts), flavoring  agents  (prunes,  peaches,  raisins,  dates,  dried 
apples),  preservatives  (salicylic  acid,  formaldehyde),  glycer- 
ine, alum  and  decolorizing  agents. 

Give  some  of  the  requisites  for  the  sanitary  construc= 
tion  of  house  foundations  and  cellars. 

To  keep  down  the  level  of  ground  water  subdrain  if  neces- 
sary to  secure  dryness.  Coat  the  foundation  inside  and  out 
with  cement  and  provide  a  cement  floor  for  the  cellar.  Admit 
plenty  of  air  and  sunlight  into  the  cellar. 

What  is  your  view  concerning  the  propriety  or  neces= 
sity  of  inserting  vaccine  virus  in  multiple  places? 

The  duration  of  the  protection  from  small-pox  is  said  to 
be  directly  proportionate  to  the  number  and  size  of  vaccine 
vesicles;  so  vaccinate  in  at  least  two  different  places  and 
let  the  combined  area  of  vesicle  resultant  measure  over  half 
an  inch. 

Give  the  prophylaxis  of  the  filth  diseases. 

Sanitary  inspection  of  all  houses  and  buildings  with  im- 
mediate abatement  of  any  nuisances.  Thorough  cleanliness 
applied  to  persons,  habitations  and  the  community,  and  to 
houses  of  public  use.  Examination  of  water  and  food  sup- 
plies, with  correction  of  all  disease-exciting  causes.  Sewage 
and  waste-removal  systems  to  be  placed  in  perfect  operation. 
Isolation  of  patients  sick  with  these  diseases,  and  disinfection 
of  rooms  and  property  of  such  patients,  and  the  establishment 
of  house,  municipal,  state  or  national  quarantine.  Prevent 
access  of  flies  and  other  insects  to  food  and  drink. 


HYGIENE.  519 

What  is  the  physical  training  for  a  weak  heart  when 
no  valvular  lesions  exist? 

Beginning  with  gentle  calisthenics,  exercise  should  be  taken, 
preferably  in  the  open  air,  ajid  increased  gradually,  such 
■exercise  to  be  supervised  by  a  competent  physician.  Later 
on  climbing  exercises  of  a  very  gradually  increasing  degree 
•of  difficulty  may  be  taken. 

How  many  cubic  feet  or  fresh  air  per  hour  are  required 
Ijy  an  adult? 

Three  thousand  cubic  feet. 

Discuss  the  theory  of  hereditary  tendencies  as  applied 
to  tuberculosis. 

Children  born  of  tuberculous  parents  present  less  power  to 
combat  and  overcome  the  attacks  of  the  tubercle  bacilli  than 
others  of  more  healthy  parents.  Some  theorists  claim  that 
this  deficiency  of  resistance  is  in  part  due  to  an  inherited 
small  heart,  and  lessened  circulatory  power,  thus  favoring 
conditions  of  passive  congestion  or  low  grades  of  inflamma- 
toiy  processes.  Such  subjects  as  a  rule  show  lessened  lung 
expansion,  a  flattened  or  a  wedge-shaped  chest,  etc. 

Describe  the  physiological  action  of  alcohol. 

Small  or  therapeutic  doses  increase  the  pulse  rate  and  the 
arterial  pressure  by  directly  stimulating  the  heart.  Over- 
doses directly  depress  and  paralyze  the  heart  muscle.  Large 
doses  produce  decided  lowering  of  body  temperature.  It  is 
probable  that  the  use  of  alcohol  diminishes  the  elimination  of 
CO^.  Alcohol  causes  a  great  lessening  in  the  excretion  of  the 
products  of  tissue  waste.  It  is  probable  that  alcohol  in  not 
too  large  quantity  is  entirely  destroyed  in  the  body.  In 
small  doses  alcohol  acts  as  a  cerebral  stimulant,  while  larger 
-doses  greatly  depress  and  abolish  nervous  activity,  and  check 
digestion.  The  habitual  use  of  alcohol  is  accompanied  by  a 
disposition  towards  fatty  degeneration,  particularly  of  heart 
imi.scle,  liver  and  kidneys,  and  in  enlarged  and  dilated  con- 


520  HYGIENE. 

dition  of  the  smaller  blood-vessels  and  a  degeneration  of  all 
nervous  structures. 

Does  alcohol  possess  a  food  action?  On  what  do  you 
base  your  answer? 

Yes.  "  In  the  sense  that  it  is  destroyed  in  the  system  and 
yields  force  which  is  utilized  by  the  organism,  and  is  when 
in  sufficient  quantity  a  retarder  of  tissue  change,  checking 
the  excretion  of  nitrogen"  (H.  C.  Wood).  We  see  this  in 
its  administration  in  typhoid  and  other  long-continued  fevers. 
Yet  it  is  not  a  true  food,  since  it  also  exerts  toxic  effects, 
which  foods  do  not. 

State  your  views  on  compulsory  vaccination  and  relate 
the  safeguard  that  should  be  employed  in  all  cases  of 
vaccination. 

The  unprotected  individual  should  be  vaccinated  as  a  pro- 
tection to  himself  and  to  those  with  whom  he  comes  in  contact. 
The  virus  employed  must  be  free  from  contamination,  the- 
instruments  used  should  be  perfectly  sterile  and  the  operation 
should  be  performed  on  a  clean  surface.  The  wound  should 
be  adequately  protected  from  irritation  by  clothing,  and  from 
pathogenic  germs. 

In  the  pursuit  of  what  trades  is  there  a  predisposition 
to  pulmonary  diseases? 

Trades  carried  on  in  over-crowded,  poorly  ventilated  rooms, 
in  damp  localities.  Trades  that  give  rise  to  much  dust,  par- 
ticularly if  such  dust  be  of  fine,  hard  particles,  to  which  file- 
makers,  stone-cutters,  grinders,  etc.,  are  subjected.  Such 
trades  as  necessitate  cramped  positions  of  the  workers  pre- 
venting proper  lung  expansion.  In  vocations  giving  rise  to- 
poisonous  or  obnoxious  vapors,  and  also  where  the  individual 
is  exposed  to  sudden  changes  of  temperature. 

Under  what  condition  is  tyrotoxicon  found  in  milk, 
cheese  and  other  articles? 

Where  milk,  cheese,  ice  cream,  etc.,  undergo  decomposition.- 


HYGIENE.  521 

in   the  presence   of  other  org'anic   matter,   as   rotting-  wood, 
mould,  etc. 

The  excavation  of  streets  in  cities  is  frequently  foI= 
lowed  by  the  outbreak  of  disease,  such  as  diphtheria, 
typhoid  fever.    What  is  the  cause? 

Pathogenic  bacteria  lie  dormant  in  the  soil  of  cities,  and 
when  such  soil  is  exposed  to  the  air,  it  becomes  dried,  and 
its  contained  bacteria  taking  on  an  active  existence  are  liber- 
ated and  carried  by  the  air  to  susceptible  individuals. 

Describe  the  agency  of  the  ptomaines  in  inducing  dis= 
eases  and  the  disorders  produced  by  them. 

Ptomaines  are  alkaloidal  bodies  resulting  from  decomposi- 
tion of  nitrogenous  substances.  When  absorbed  into  the 
blood  they  may  give  rise  to  fever,  headache,  torpor,  fetid 
breath.  They  act  like  chemical  poisons  very  soon  after  their 
introduction  into  the  system.  Many  of  them  occasion  dis- 
tinctive trains  of  symptoms. 

How  long  does  a  diphtheritic  patient  remain  infective? 
How  may  it  be  proved  that  this  infective  period  has 
ceased? 

About  three  weeks  after  local  symptoms  cease.  Make  fre- 
quent cultures  of  material  from  the  affected  site,  and  when 
such  fail  to  show  the  specific  germ,  the  patient  will  no  longer 
be  a  source  of  infection. 

How  may  milk  be  the  means  of  transmitting  the  germs 
of  typhoid  fever? 

Through  water  containing  Eberth's  bacillus  gaining  access 
to  the  milk,  as  through  diluting  the  milk,  wa-shing  milk  re- 
ceptacles in  polluted  water. 

State  the  period  of  incubation  in  (a)  vaccinia;  (b)  paro- 
titis; (c)  pertussis;  (d)  varicella;  (e)  rotheln. 

(a)  3  to  7  days;  (b)  14  to  22  days;  (e)  2  to  8  days:  (d) 
4  to  14  days;  (e)  12  to  20  days. 


522  HYGIENE. 

Mention  the  effects  of  working  in  phosphorus,  as  in  the 
manufacture  of  phosphorus  matches.  How  can  the  dan= 
gers  be  limited  or  prevented? 

Inhaling  phosphorus  fumes  produces  a  form  of  necrosis  of 
the  jaw,  particularly  in  such  as  have  imperfect  teeth.  To 
avoid  its  development  persons  with  sound  teeth  and  freedom 
from  abrasion  of  the  interior  of  the  mouth  should  be  em- 
ployed. The  work-room  should  be  large  and  well  ventilated, 
with  special  air-shaft  to  force  the  fumes  away  from  face  of 
workers,  the  employees  should  have  short  working  hours,  and 
frequently  use  a  mouth  wash  and  gargle  of  lime  water  or 
carbonate  of  sodium.  Turpentine  and  charcoal  should  be 
exposed  in  the  room. 

What  fruits  are  preferable  in  cases  of  habitual  consti= 
pation? 

Apples,  prunes,  figs,  tamarinds,  grapes  and  melons. 

Indicate  a  proper  diet  in  the  case  of  diabetes  mellitus, 
obesity  and  early  convalescence  in  typhoid  fever. 

The  diabetic  should  use  only  a  small  quantity  of  carbo- 
hydrate foods,  with  a  relatively  large  quantity  of  proteid 
foods  and  fats.  The  patient  suffering  from  obesity  should 
use  but  little  fluids  or  food  containing  much  water.  Food 
containing  starch  and  sugar  should  be  eaten  sparingly,  and 
alcoholic  liquors  and  fats  must  be  avoided  entirely.  He 
should  eat  lean  meats,  mutton,  beef,  lamb,  chicken,  eggs,  stale 
bread  or  toast  sparingly,  tomatoes,  lettuce,  celery,  asparagus, 
onions,  ripe  fruits  of  an  acid  nature  but  no  sugar. 

In  convalescence  from  typhoid  fever  the  patient  should  use 
easily  digestible  food  of  a  concentrated,  nourishing  character, 
of  small  bulk  and  without  hard  or  irritating  properties,  as 
soups,  broths,  uncooked  oysters,  eggs,  rice,  wine,  milk,  calves' 
foot  jelly,  etc. 

What  is  the  chief  unsanitary  condition  of  sea=going 
vessels? 

The  presence  of  bilge  water  and  dirty  hold. 


HYGIENE.  523 

Describe  the  manner  in  which  antitoxin  is  prepared. 

A  virulent  culture  of  the  specific  micro-organism,  or  a 
strong  toxin  is  injected  into  the  cellular  tissue  of  the  selected 
animal,  under  due  precautions  of  aseptic  operation.  After 
the  animal  has  recovered  from  the  symptoms  thus  produced, 
another  and  stronger  injection  of  the  specific  poison  is  given. 
Injection  after  injection  of  increasing  strength  is  given  at 
proper  intervals,  until  the  animal  fails  to  show  any  further 
symptoms  of  the  disease — after  an  injection.  Blood  is  then 
taken  from  the  jugular  vein  of  the  animal,  the  greatest  care 
being  observed  to  secure  aseptic  conditions.  This  blood,  re- 
ceived in  sterilized  flasks,  which  are  then  stoppered,  is  stored 
in  refrigeratoi-s  until  separation  of  clot  and  serum  occurs. 
The  serum  is  now  tested  to  determine  its  value  as  antitoxin 
and  then,  after  the  addition  of  a  very  small  proportion  of 
carbolic  acid,  is  placed  in  small  vials,  which  are  then  her- 
metically sealed.  Each  vial  has  marked  upon  it  its  strength 
in  normal  antitoxin  units  in  each  cubic  centimeter,  and  usually 
contains  one  dose. 

Mention  some  of  the  objections  to  curbed  or  driven 
wells  in  streets  or  houses  with  respect  to  the  purity  of 
water  coming  from  these  wells. 

The  curbing  rarely  affords  protection  to  the  well  water 
from  gases  and  other  emanations  from  sewers,  gas-pipes, 
drains,  etc.,  and  even  though  a  driven  piped  well  may  take 
its  water  from  far  below  the  surface,  yet  in  the  streets  of 
cities,  with  the  ever-present  sewer  and  gas  pipes,  the  soil 
becomes  so  saturated  with  deleterious  material  as  to  greatly 
endanger,  through  water  carnage,  the  water  from  all  forms 
of  wells. 

From  what  disease  may  immunity  be  acquired  in  the 
case  of  persons  who  have  once  suffered  from  these  dis- 
eases? How  is  knowledge  of  this  fact  utilized  in  the 
prevention  of  certain  diseases? 

Yellow   fever,   small-pox,   scarlet   fever,    chicken-pox,    per- 


524  HYGIENE. 

tussis,  typhus  fever,  cholera.     A  partial  immunity  may  result 
in  measles,  mumps  and  in  typhoid. 

We  may  prevent  some  of  these  diseases  by  the  introduction 
into  the  patient's  system  of  the  particular  antitoxin  of  the 
threatened  disease. 

Describe  the  effect  of  a  hot  and  moist  climate  on  the 
human  system,  and  state  the  class  of  diseases  this  atmos= 
phere  is  likely  to  induce. 

In  hot  and  moist  climates  the  inhabitants,  as  a  rule,  are 
of  small  stature  and  deficient  in  muscular  development ;  of 
languid  disposition  and  nervous  temperament.  The  diseases 
most  prevalent  are  those  affecting  the  liver  and  gastro-intes- 
tinal  tract;  also  various  forms  of  malaria,  yellow-fever  and 
other  parasitic  diseases. 

What  occupations  are  a  menace  to  public  health?   Why? 

Those  occupations  that  emit  irritating,  poisonous  or  nox- 
ious fumes  and  gases,  from  the  vitiation  of  the  atmosphere, 
as  in  fertilizing  plants,  chemical  manufactories,  bone-boiling 
establishments;  also  dust,  especially  if  this  be  of  sharp,  hard 
character,  as  from  cement-making,  tool-making,  the  respi- 
ratory tract  being  thereby  subjected  to  irritation. 

Mention  some  of  the  objections  to  storage  cisterns  under 
ground.   What  are  the  objections  to  rain  water  as  a  drink? 

They  often  receive  dust  and  dirt;  sewer  gas  may  gain 
entrance  to  the  water  when  the  "standing  waste"  or  over- 
flow pipe  of  such  a  cistern  is  connected  with  the  drain  or 
soil  pipe  of  a  house.  Storage  cisterns  cannot  be  properly 
ventilated,  and  are  often  difficult  to  clean. 

If  the  first  part  of  the  rain  be  collected,  such  water  will 
contain  dust,  pollen,  gases  and  other  matters  washed  from 
the  air. 

Mention  some  of  the  diseases  to  which  artisans  are 
especially  liable. 

Painters,  and  those  working  in  lead,  copper  and  zinc,  may 


HYGIENE.  525 

sulit'ei-  from  metallic  poisoning;  match-makers  from  phos- 
phorus poisoning;  tool-makers  and  grinders  from  phthisis; 
miners  from  affections  of  bronchi  and  lungs ;  smelters  from 
arsenical  poisoning. 

Given  an  opinion  as  to  the  sanitary  effect  of  the  differ^ 
ent  methods  of  heating  houses. 

The  most  desirable  method  is  by  hot  water  heating  by 
means  of  a  complete  plant  with  circulation  of  the  hot  water 
through  radiators.  Next  in  value  to  hot  water  heating  is 
steam  heating  by  radiator  or  by  indirect  radiation.  The  use 
of  open  fireplaces  in  the  principal  rooms  is  of  great  value  in 
securing  ventilation,  but  yields  an  unequal  and  insufficient 
supply  of  heat.  Heating  a  house  by  hot  air  from  basement 
heaters  is  efficient  and  gives  good  results,  if  the  air  supplied 
to  the  heater  for  distribution  is  pure  and  the  houae  is  not 
too  large. 

State  average  weight  of  feces  in  24  hours  in  a  normal 
man.  What  proportion  is  made  up  of  liquid  and  what  of 
solid  contents?   i    ^O      u 

Tweirt7=fowis.©4uicea,  75  per  cent,  of  which  is  water. 

Name  eight  principal  carbohydrates  used  as  food. 

Starch,  glucose,  saccharose,  lactose,  dextrin,  cellulose,  mal- 
tose and  dextrose. 

Name  the  class  of  foods  which  should  be  given  to  chil= 
dren  between  the  first  and  second  years  of  age. 

We  should  supply  foods  in  about  the  proportion  of  2  parts 
proteid,  3  parts  fat,  6  parts  carbohydrates,  tlie  proteid  food 
preferably  milk. 

How  do  forests  benefit  public  health? 

Forests  act  as  wind  barriei*s,  promote  humidity  of  the  air 
from  the  widespread  surface  they  offer  for  evaporation. 
They  afford  shade  in  summer,  and  aid  in  decreasing  the  rela- 
tive quantity  of  carbon  dioxide  in  the  air,  exhaling  oxygen  to 
the  air. 


526  HYGIENE. 

State  in  a  general  way  the  maximum  number  of  hours 
that  primary  pupils  in  the  public  schools  should  be  kept 
at  their  tasks,  and  how  frequently  and  in  what  manner 
such  tasks  may  be  varied  and  broken. 

One-half  hour  at  a  given  task  is  sufficient,  after  that  th& 
character  of  the  mental  work  should  be  changed.  When  an, 
hour's  mental  application  has  been  enforced,  then  five  or  ten 
minutes  should  be  given  to  light  calisthenics.  An  intermisr 
sion  of  fifteen  or  twenty  minutes  in  the  open  air  should 
occur  in  the  course  of  three  hours'  study.  An  intermission 
of  two  hours  should  then  be  allowed  for  luncheon  and  recrea- 
tion, at  the  end  of  which  time  a  similar  routine  may  be  fol- 
lowed, as  stated  above,  for  two  hours. 

What  abnormal  condition  of  the  eye  is  most  common 
in  school  children? 

Myopia. 

What  are  some  of  the  dangers  involved  in  the  domestic 
use  of  ice? 

Ice  may  contain  pathogenic  bacteria,  and  may,  when  re- 
moved from  a  sick-room  transmit  infectious  disease  to  other 
members  of  the  household. 

What  is  the  expectation  of  life  of  a  professional  man 
in  active  practice  at  the  age  of  45  years? 

24.82  years. 

Define  the  term  "quarantine;"  mention  the  principal 
quarantinable  diseases,  and  give  the  rules  for  determining 
the  length  of  time  each  should  be  quarantined. 

''The  adoption  of  restrictive  measures  to  prevent  the  in- 
troduction of  disease  from  one  country  or  locality  into  an- 
other" (Wyman). 

Quarantinable  diseases  inchide  cholera,  small-pox,  yellow 
fever,  plague,  scarlet  fever,  diphtheria,  typhus  fever,  relaps- 
ing fever,  cerebro-spinal  meningitis,  leprosy. 

In  eruptive  fevers  isolation  of  the  patient  (quarantine)  is 


HYGIENE.  527 

continued  for  two  weeks  after  the  eruption  has  disappeared 
except  in  the  case  of  small-pox  where  quarantine  lasts  30  days. 
The  quarantine  in  diphtheritic  cases  does  not  cease  until 
cultures  made  from  the  throat  of  the  patient  fail  to  show 
the  bacillus  of  diphtheria. 

State  the  best  means  of  disinfecting  sputum. 

Sputum  should  be  burned  or  be  received  into  vessels  con- 
taining strong  antiseptic  solutions. 

What  is  understood  by  the  germ  theory  of  disease? 
Mention  all  diseases  whose  causes  are  known  to  be  spe= 
cific  micro=organisms. 

The  germ  theory  of  disease  contends  that  the  exciting 
cause  of  each  infectious  or  contagious  disease  is  some  specific 
organism,  and  that  these  diseases  are  communicated  only  by 
the  transference  to  and  development  of  the  particular  para- 
site or  germ  within  or  upon  the  tissues  of  the  infected  in- 
dividual. 

Diseases  due  to  specific  micro-organisms  are  tuberculosis, 
diphtheria,  cholera,  typhoid  fever,  dysentery,  pneumonia, 
glanders,  leprosy,  anthrax,  erysipelas,  gonorrhea,  relapsing 
fevei",  tetanus,  plague,  malaria  and  syphilis. 

What  diseases  are  incident  to  school  life?  How  may 
these  diseases  be  prevented? 

The  infectious  diseases,  which  should  be  prevented  by  early 
recognition  and  prompt  removal  of  sick  pupils.  The  room 
should  be  disinfected.  Curvature  of  the  spine  should  be  cor- 
rected or  prevented  by  properly  constructed  school  furniture, 
and  proper  admission  of  light  to  the  room.  Myopia  should 
1)6  prevented  by  the  use  of  clear,  large  print  in  text-books 
and  correction  of  improper  positions  in  reading  and  writing 
and  a  good  supply  of  light  admitted  to  the  school-room  to 
the  left  of  the  pupils. 

Contagious  conjunctivitis,  prevented  by  doanliness  and 
isolation  of  the  patiejnt. 


528  HYGIENE. 

Chorea,  prevented  by  removal  of  the  afflicted  and  repres- 
sion of  all  the  tendencies  toward  imitation. 

What  is  the  value  of  preventive  inoculation  in  cholera 
and  diphtheria? 

Value  in  cholera  not  yet  fixed.  In  diphtheria,  antitoxin  is 
both  curative  and  prophylactic. 

Outline  the  construction  of  a  camp  hospital,  especially 
providing  for  the  care  (with  least  danger  to  other  patients, 
medical  and  surgical)  of  those  suffering  from  contagious 
diseases. 

Obtain  purity  of  internal  atmosphere;  abundance  of  pure 
air  and  sunlight  within  the  building,  facility  of  administra- 
tion and  discipline.  To  obtain  these  requirements  select  a 
proper  site  of  soil,  not  clay,  and  preferably  on  hillside,  look- 
ing southward  if  in  winter;  use  a  simple  plan  of  building, 
a  sufficient  number  of  wards,  preferably  on  the  detached  or 
pavilion  plan.  In  wards  each  patient  should  have  at  least 
90  square  feet  of  surface  space,  and  1,200  cubic  feet  of  air 
space;  have  provisions  for  burning  all  infected  material,  dis- 
charges, etc.,  to  leew^ard  of  the  hospital  and  at  suitable 
distance  away. 

Can  it  be  proved  that  the  diminished  death  rate  from 
diphtheria  so  generally  announced  is  due  to  the  use  of 
diphtheria  antitoxin?    Give  reasons. 

Yes.  By  comparing  the  death  rate  in  hospitals  treating 
the  same  class  of  patients,  in  the  same  community,  during  the 
same  time,  the  one  hospital  using  diphtheria  antitoxin,  the 
other  depending  upon  other  methods  of  combating  the  dis- 
ease. Where  the  antitoxin  is  used  the  death  rate  is  mucli 
lower. 

Give  the  comparative  nutritive  value  of  sterilized  or 
unsterilized  cows'  milk. 

The  nutritive  value  of  sterilized  milk  is  less  than  that  of 
milk  unsterilized. 


HYGIENE.  529 

What  evil  consequences  frequently  result  from  the  ex= 
cessive  use  of  tobacco? 

Catarrhal  inflammation  of  pharynx,  tonsils  and  mouth. 
Nervous  disorders  of  heart  as  palpitation,  and  insomnia  also 
result.  Derangements  of  stomach  with  loss  of  appetite,  and 
impairment  of  vision  together  with  paralysis  of  optic  nerve, 
nervous  tremors,  and  muscular  twitching  may  result. 

How  should  a  patient  who  has  been  rendered  uncon= 
scious  by  heat  be  treated? 

If  the  patient  has  a  strong,  full  pulse  and  the  face  is  red 
and  congested,  place  him  in  a  recumbent  position  with  the 
head  raised  and  apply  ice  until  the  high  temperature  falls 
to  about  100  degrees  Fahr. 

If  the  patient  is  pale,  with  a  weak  pulse,  use  stimulants, 
as  ammonia,  by  inhalation ;  apply  heat  to  the  body  and  keep 
head,  face  and  neck  cool. 

Mention  some  of  the  advantages  of  carefully  prepared 
artificial  ice  as  compared  with  natural  ice. 

It  may  be  made  from  distilled  water  so  as  to  be  absolutely 
pure.  It  may  be  obtained  in  any  size  or  shape  and  its  tex- 
ture is  more  uniform. 

What  precautions  as  to  food  and  drink  should  be  ob= 
served  by  those  forced  to  work  under  the  direct  rays  of 
the  sun  in  summer  weather? 

A  small  quantity  of  readily  digestible  food  should  be  eaten 
before  going  to  work.  Liquids  of  a  non-alcoholic  character 
may  be  used  liberally,  provided  perspiratory  function  is  ac- 
tively performed.  Very  cold  drinks  should  be  avoided.  Meat 
should  be  largely  excluded  from  the  diet. 

A  law  to  prevent  owners  of  land  in  the  narrow  streets 
of  New  York  City  from  erecting  buildings  more  than 
twelve  stories  in  height  is  being  agitated.  Give  sanitary 
and  hygienic  reasons  for  and  against. 

Reasons   favoring   tall   buildings :    The   pei-sons  using   the 
34 


530  HYGIENE. 

upper  flooi-s  are  insured  uninterrupted  sunshine,  good  light, 
a  pure  air  comparatively  free  from  street  dust,  and  free- 
dom from  ground  air  and  water. 

Reasons  against :  Tall  buildings  prevent  proper  ventilation 
of  lower  buildings,  and  obscure  sunlight  from  smaller  build- 
ing's and  the  street.  Fire  is  difficult  to  extinguish  in  tall 
buildings.  Their  lower  floors  are  often  damp  and  generally 
dark,  requiring  the  constant  use  of  artificial  illumination. 
They  are,  therefore,  a  menace  to  the  lives  of  their  occupants. 

What  are  the  best  methods  of  ventilating  dwellings^ 
and  what  sanitary  principles  are  involved? 

The  perflating  action  of  wind  should  be  utilized  at  least 
once  each  day  for  all  rooms.  One  of  the  best  methods  em- 
ployed is  the  open  fireplace,  provided  such  fireplaces  be  sup- 
plied with  properly  constructed  chimney  exits.  In  lieu  of 
this  plan  fresh  air  may  be  admitted  through  ventilators,  or 
between  the  upper  and  lower  window-sashes.  The  object 
sought  in  these  devices  is  to  admit  cold  air  above  the  heads 
of  the  occupants  of  the  room  so  that  the  fresh  air  may  pass 
through  the  upper  portions  of  the  room  and  become  heated 
before  reaching  the  occupants.  The  usual  outlet  for  foul  air 
is  the  chimney  flue,  but  when  this  is  not  present,  it  may  be 
replaced  by  an  opening  for  the  exit  of  air  placed  near  the 
ceiling  of  each  room.  During  cold  weather  the  rate  of  inter- 
change of  air  should  not  be  greater  than  sufficient  to  change 
the  air  of  the  room  three  times  an  hour.  The  air  which  en- 
ters should  not  have  a  greater  velocity  than  five  feet  per 
second,  or  about  3.4  miles  per  hour. 

What  hygienic  precautions  should  be  observed  in  the 
care  of  the  new=born  child? 

The  room  should  be  kept  at  a  temperature  of  about  72° 
Fahr.  and  well  ventilated  without  draught.  The  child  should 
be  thoroughly  cleansed,  using  a  neutral  fat  to  facilitate  the 
removal  of  all  fatty  or  sebaceous  material  before  washing 
\Y\\h.  warm  water  and  castile  soap.     The  eyes  and  surround- 


HYGIENE.  531 

ing  parts  should  iu  particular  be  thoroughly  cleansed;  if 
passible,  without  the  aid  of  soap.  After  thoroughly  drying 
the  infant,  its  navel  should  be  properly  dressed.  The  infant 
should  then  be  warmly  clad,  kept  dry  and  clean,  and  away 
from  noise  and  strong  light. 

What  hygienic  precautions  are  necessary  to  insure 
healthy  sleep? 

A  well-ventilated  room,  temperature  about  60°  F.  Room 
and  bed  should  be  perfectly  clean,  and  the  covers  of  the  bed 
not  too  heavy.  The  head  of  the  pereon  should  be  slightly 
elevated.  Noise  and  light  should  be  excluded  from  sleeping 
apartments. 

What  deleterious  gases  accumulate  in  improperly  ven= 
tilated  sleeping  rooms? 

Carbon  dioxide;  carbon  monoxide,  if  rooms  be  heated;  hy- 
drogen sulphide ;  ammonium  sulphide,  and  many  gases  of  an 
organic  ammoniacal  character. 

Does  change  in  climate  require  any  change  in  food;  if 
so,  what? 

Yes.  In  cold  climates  a  greater  quantity  of  food  should 
be  consumed  than  in  hot  climates.  Food  that  is  productive 
of  the  greatest  number  of  heat  units,  as  fats  and  meats, 
should  be  partaken  of  in  cold  climates.  In  hot  climates  the 
diet  should  consist  almost  entirely  of  well-cooked  vegetables 
and  ripe  fruits,  with  the  avoidance  of  alcoholic  beverages. 

What  are  some  of  the  dangers  of  the  cold  bath? 

In  those  of  feeble  circulation  and  at  the  two  extremes  of 
life,  chilling  of  the  surface  of  the  body  leading  to  internal 
congestion  that  may  result  in  acute  inflammation,  particu- 
larly of  the  lungs,  kidneys,  stomach  and  bowels.  Shock  seri- 
<msly  affecting  the  heart ;  and  the  production  of  a  persistently 
lowered  temperature  of  the  body. 

What  effect  has  ground  air  and  water  on  the  health? 

•  Jfoiind    Mil-    is    always    impure,    being   contaminated    with 


532  HYGIENE. 

bacteria,  carbon  dioxide  and  often  with  more  poisonous 
gases.  It  occasions  various  degrees  of  ill-health,  varying  from 
slight  general  malaise  to  one  of  the  acute  infectious  diseases 
or  tuberculosis.  Ground  water  from  near  the  surface  of  pol- 
luted soils  may  be  noxious.  It  causes  dampness  of  the  walls 
of  houses,  inviting  rheumatic  diseases  and  catarrhal  inflam- 
mations. 

What  hygienic  principles  should  be  observed  in  infants 
feeding? 

Feed  the  child  every  few  hours  during  the  day ;  and  about 
three  times  during  the  night  till  several  months  old;  then 
less  frequently.  If  possible  let  the  child  receive  its  natural 
food  from  the  mother,  and  in  such  cases  take  particular  pains 
to  see  that  the  nipples  and  breasts  of  the  mother  are  kept 
dry  and  clean  between  the  times  of  nursing.  If  the  infant 
is  to  be  given  artificial  feeding,  the  cow's  milk  selected  must 
be  from  a  healthy  animal,  must  be  diluted  with  water  to 
give  a  relatively  less  proportion  of  casein,  must  be  sweetened 
with  milk  sugar,  and  have  a  slight  addition  of  fats  in  the 
form  of  cream  added,  when  it  will  approach  human  milk  in 
composition.  A  definite  quantity  of  milk  which  should  be 
warmed  to  the  temperature  of  the  body  should  be  given  at 
each  feeding. 

Define  the  word  "  nuisance  "  in  a  broad  hygienic  sense. 

"Something  which  either  actually  injures,  or  is  likely  to 
injure  health,  and  admits  of  a  remedy  either  by  the  indi- 
vidual whose  act  or  omission  causes  the  nuisance,  or  by  the 
local  authority"  (Wynter-Blyth). 

What  should  be  the  height,  weight  and  chest  measure 
of  a  typical  man  aged  25  years? 

Height  67.8  inches;  weight  139  pounds;  measurement  of 
chest  34.5  inches. 

What  injurious  influences,  if  any,  do  cemeteries  exert 
on  the  health  of  persons  living  in  their  vicinity? 

To  most  persons  the  mental  effect  is  depressing.     Water 


HYGIENE.  533 

passing  through  the  soil  of  cemeteries  may  contaminate  the 
water  supply  of  the  neighborhood  with  organic  material  and 
micro-organisms.  The  constant  turning  of  soil  of  cemeteries 
may  set  free  imprisoned  gases  from  organic  decomposition, 
and  lead  to  contamination  of  the  surrounding  air. 

What  physical  conditions  would  render  the  taking  of  a 
Turkish  bath  inadmissible? 

Atheromatous  arteries  generally,  diseases  of  the  lungs,  and 
diseases  of  the  heart. 

What  gases  and  combination  of  gases  are  most  efficient 
as  disinfectants? 

Formaldehyde,  sulphur  dioxide,  chlorine,  ozone. 
What  care  should  be  employed  in  exhumations? 

The  exhumation  of  those  dead  of  contagious  or  infectious 
diseases  should  not  be  allowed.  When  possible,  the  exhuma- 
tion should  be  deferred  until  cold  weather.  The  presence  of 
all  persons  except  those  absolutely  needed  should  be  forbidden. 
As  the  workmen  approach  the  coffin  the  earth  should  have 
poured  upon  it  a  strong  watery  solution  of  creolin.  The 
coffin  containing  the  remains  should  not  be  opened,  but  be 
placed  at  once  in  a  zinc-lined  box  and  hermetically  sealed. 

What  are  the  hygienic  requirements  and  the  physio- 
logical effects  of  bathing? 

The  bath  should  be  taken  to  obtain  personal  cleanliness,  as 
well  as  for  its  stimulation  of  the  peripheral  circulation. 
Bathing  should  be  postponed  until  at  least  two  hours  after  a 
meal,  and  should  consume  only  twenty  minutes.  Never  bathe 
when  very  hungry,  or  when  the  body  is  overheated.  Unless 
experience  has  shown  that  good  effects  accrue  from  a  cold 
bath,  secure  a  temperature  of  about  65  to  75  degrees  Fahr. 
of  the  water.  The  bath  should  be  followed  by  a  thorough 
drying  and  brisk  rubbing.  Effects  following  a  bath  are  re- 
moval of  dirt  and  of  dead  epithelium  from  the  person,  stim- 
ulation of  the  functional  activities  of  the  skin;  a  general 
improvement  of  the  organs  of  elimination. 


534  HYGIENE. 

How  much  fresh  air  is  required  for  normal  respiration 
during  24  hours? 

3,000  cubic  feet  per  hour,  or  72.000  cubic  feet  of  air  in 
24  hours. 

What  is  the  best  sanitary  disposition  of  stable  manure 
in  large  cities? 

The  liquid  portion  of  manure  should  be  carried  by  prop- 
erly constructed  trapped  drains  into  the  general  sewer.  The 
solid,  dried  manure,  straw,  etc.,  should  be  placed  in  well- 
covered  pits,  from  which  it  could  be  removed  at  proper  in- 
tervals in  covered  wagons,  and  employed  in  the  country  as 
fertilizer;  or  drain  the  liquid  manure  into  the  sewer  and 
cremate  the  solid  manure. 

How  may  a  privy  in  a  city  or  country  be  kept  while  in 
use  from  becoming  a  nuisance? 

Have  the  privy  emptied  at  frequent  intervals.  At  inter- 
vals of  five  to  seven  days,  pour  into  the  privy  vault  milk  of 
lime  (about  20  grains  of  lime  for  each  gallon  of  sewage), 
or  strong  solution  of  iron  sulphate;  or  at  frequent  intervals 
add  clean,  dry  earth  to  the  privy  contents,  and  provide  a 
ventilating  pipe  extending  high  in  the  air  and  down  into  the 
privy  vault. 

What  explanation  can  be  furnished  for  the  greater  prev= 
alence  of  diphtheria  and  smalhpox  in  cold  than  in  warm 
weather? 

During  cold  weather  the  houses  are  less  perfectly  venti- 
lated than  in  warm  weather.  Rooms  are  frequently  over- 
crowded, less  attention  is  paid  to  personal  cleanliness  and 
there  are  more  sudden  changes  in  temperature.  Such  condi- 
tions lower  the  vitality  of  the  body  and  predispose  to  disease. 

What  are  the  principal  adulterations  of  milk? 

Addition  of  water  and  abstraction  of  cream;  addition  of 
coloring  matter  (annatto,  caramel)  ;  preservatives  (borax  and 
boric  acid,  salicylic  acid,  formaldehyde,  chromates)  ;  gela- 
tine as  a  thickening  for  cream. 


HYGIENE.  535 

What  changes  in  food  are  effected  by  cooking? 

Parasites  and  germs  are  destroyed;  the  food  is  made  more 
tender  to  facilitate  mastication.  The  tough  fibrous  envelope 
of  starch  cells  is  softened,  albumin  is  coagulated,  the  food 
is  rendered  more  palatable,  and  the  action  of  the  different 
digestive  fluids  is  aided. 

Give  the  sanitary  dimensions  of  a  schooI=room  for  fifty 
pupils. 

A  room  15  feet  high,  25  feet  wide  and  40  feet  long  would 
allow  each  pupil  300  cubic  feet  of  space,  which  is  the  ade- 
quate amount  for  each  child. 

Mention  eight  satisfactory  disinfectants  and  give  indi= 
cations  for  their  use. 

Formaldehyde  (1  pound  of  formalin  for  every  1000  cu.  ft. 
of  space),  sulphur  (3  pounds  for  every  1000  cu.  ft.  of  space) 
or  bleaching  powder  (3  pounds  for  every  5000  cu.  ft.  of 
space)  to  fumigate  a  room.  If  sulphur  or  blea-ching  powder 
are  used,  it  is  necessary  to  steam  the  room  before  beginning 
to  fumigate.  Chloride  of  lime  to  disinfect  excreraentitious 
matter  from  typhoid  fever,  cholera,  dysentery,  etc.  .  Carbolic 
acid  (5%  solution)  or  moist  heat  (steam  and  boiling  water) 
to  disinfect  clothing.  Bichloride  of  mercury  or  permanga- 
nate of  potassium  and  oxalic  acid  to  disinfect  the  skin. 

What  are  the  most  common  sources  of  infection  in 
diphtheria? 

By  direct  contact  with  the  sputum  or  shreds  of  membrane 
from  the  patient.  By  inhaling  the  air  in  the  vicinity  of  the 
patient.     By  fomites,  as  clothing,  books,  drinking-cups,  etc. 

What  conditions  are  essential  to  a  good  water  supply? 

Purity  at  its  source,  and  adequate  subsequent  protection 
from  contamination. 

What  hygienic  measures  should  be  observed  by  the 
nursing  woman? 

An   abundant  diet,   avoiding   overfeeding;   some   form   of 


536  HYGIENE. 

outdoor  exercise  each  day;  monotony  of  life  and  overwork 
should  be  guarded  against.  Warm  clothing,  personal  clean- 
liness, abundant  sleep,  freedom  from  mental  cares,  fright  or 
anger  are  necessary  precautions.  Each  time  the  child  is  re- 
moved from  the  breast  the  nipples  should  be  washed  with 
warm  water  and  thoroughly  dried. 

What  precautions  should  a  physician  observe  to  avoid 
carrying  contagious  diseases? 

A  linen  duster  and  a  tightly-fitting  linen  cap  should  be- 
worn  by  the  physician  in  the  sick-room,  and  be  removed 
after  leaving  the  room.  Immediately  after  manipulating  the 
patient  the  physician  should  thoroughly  wash  and  disinfect 
his  hands  and  face.  A  bath  and  change  of  clothing  before 
attending  other  patients  are  advisable. 

Describe  the  hygiene  of  the  mputh  and  teeth. 

The  teeth  should  be  cleansed  after  each  meal  and  on  rising 
in  the  morning,  and  foreign  matter  between  the  teeth  should 
be  removed.  Acidity  of  the  saliva  may  be  counteracted  by 
weak  alkaline  mouth  washes. 

What  methods  would  you  suggest  for  the  hygienic  care 
of  the  skin? 

Simple  foods:  avoiding  constipation;  daily  exercise  in  the 
open  air;  plenty  of  sleep  (at  least  eight  hours  daily)  ;  fre- 
quent warm  baths  and  a  cold  sponge  bath  on  rising  each 
morning. 

What  localities  should  be  sought  or  avoided  by  rheu- 
matic patients? 

Warm,  dry,  equable  climate  should  be  sought.  Alkaline  or 
sulphur  thermal  springs  are  recommended.  Damp  valleys, 
shores  of  rivers,  sea  coasts  and  places  which  are  much  ex- 
posed to  winds  and  sudden  changes  of  temperature  should  be 
avoided. 

Name  the  kinds  of  food  and  the  quantity  of  each  for  the 
daily  use  of  the  normal  man. 

4.5  ounces  of  proteid;  3.5  ounces  of  fats;   14  ounces  of 


HYGIENE.  537 

carbohydrates;  1  ounce  of  salts  (Moleschott).  Or  118  grains 
proteids;  56  grains  fats;  500  grains  carbohydrates  (Voit), 
These  quantities  represent  dry  foods.  If  the  diet  is  stated 
as  so-called  solid-food  (not  water-free)  the  above  quantities 
must  be  doubled.  50  to  80  ounces  of  water  in  liquid  form 
are  also  taken  into  the  system. 

What  is  the  object  of  the  wet  pack,  and  what  unfavor= 
able  results  may  occur  from  its  use? 

The  cold  wet  pack  is  used  to  lower  temperature  during 
fever.  The  warm  wet  pack  is  used  to  promote  elimination 
of  fluid,  to  relax  muscular  spasm,  to  promote  sleep,  and  raise 
lowered  vitality. 

The  dangers  to  be  guarded  against  are  heart  failure  or 
fatigue,  or  excitement  to  weak  patients.  The  cold  pack  may 
give  the  patient  a  nervous  chill. 

Describe  in  detail  the  process  of  disinfection  by  formal  = 
dehyde  (formalin). 

Make  the  room  as  nearly  air-tight  as  possible  by  closing  all 
openings  and  cracks  before  beginning  the  process  of  disin- 
fection. All  mattresses,  pillows,  clothing,  books,  etc.,  should 
be  exposed  as  fully  as  possible  to  the  action  of  the  disin- 
fectant. Place  one  pound  of  formalin  for  every  1000  cu.  ft. 
of  air  space  in  a  "Novy"  generator.  Start  the  rapid  vola- 
tilizing of  the  formaldehyde  and  allow  the  room  to  remain 
closed  for  one  day. 

What  hygienic  means  should  be  employed  by  persons 
prone  to  "  catch  cold?  " 

A  cold  sponge  bath  followed  by  brisk  rubbing  on  arising 
in  the  morning;  daily  muscular  exercise  in  the  open  air  and 
a  liberal  (but  not  excessive)  diet,  largely  of  carbohydrates. 

Describe  the  necessary  sanitary  precautions  during  the 
prevalence  of  an  epidemic  of  Asiatic  cholera. 

Isolate  all  patients  and  attendants ;  observe  strict  quarantine 
of  all  infected  houses  or  districts;  disinfect  and  remove  any 


588  HYGIENE. 

accumulations  of  filth,  excreta,  etc. ;  cremate  those  who  have 
died  from  this  disease.  The  water  supply  should  be  guarded 
to  prevent  its  contamination  and  householders  instructed  to 
boil  all  water  or  milk  before  using"  the  same.  All  gastric 
or  intestinal  diseases  should  be  attended  to  at  once.  Restrict 
or  prohibit  the  use  of  all  fruits  or  uncooked  foods  from  the 
district;  and  use  all  disinfectant  precautions  where  cases 
exist,  during  continuance  of  case,  and  after  its  termination. 

What  are  the  sanitary  requirements  of  house  plumbing? 

All  pipes  and  connections,  traps,  etc.,  should  be  in  view  or 
easy  of  access.  Each  house  must  be  directly  connected  by 
pipe  with  the  common  sewer.  The  pipes  in  the  house  must 
be  of  iron  with  leaded  joints  or  screwed  couplings.  The 
drainage  pipes  .should  be  laid  with  a  gradient  of  at  least  one 
inch  fall  to  every  four  feet  of  length;  the  main  house  drain 
must  be  provided  with  a  trap  after  it  has  been  carried  beyond 
all  house  connecting  pipes.  Pipes  from  water-closet  fixtures, 
bath-tubs,  wash-basins  and  sinks  must  have  traps  close  to 
each  fixture.  Soil  pipes  must  extend  open  for  at  least  two 
feet  above  the  roof  and  air  must  be  admitted  to  the  main  trap 
upon  its  house-side. 

Describe  a  simple  form  of  ventilating  the  sick=room. 

Place  a  wooden  strip  about  three  inches  wide  and  as  long 
as  the  window  frame  under  the  lower  sash;  through  the 
space  between  the  top  of  the  lower  sash  and  the  bottom  of  the 
upper,  sufficient  air  will  enter  the  room  ^vithout  producing  a 
draught. 

What  precautions  should  be  taken  in  schoolrooms  to 
protect  the  sight  of  scholars? 

Pupils  should  not  sit  facing  the  windows  (the  light  should 
come  from  behind  or  over  left  shoulder)  ;  blackboards  should 
not  have  a  glossy  surface  and  should  not  be  placed  between 
windows.  The  walls  of  the  room  should  be  of  a  neutral  tint. 
Text-books  should  be  printed  in  clear,  large  type.  Faulty 
posture  in   reading  and  writing  should  be  eorrect^d  by  the 


HYGIENE.  539 

teacher.  If  toilet  accessories  are  supplied,  no  child  suffering 
with  an  inflammatory  disease  of  the  eyes  should  be  permitted 
the  use  of  the  general  supply.  Any  imperfection  in  vision 
of  a  pupil  should  be  reported  to  the  parents. 

What  are  the  chief  sources  of  contamination  to  drink= 
ing  water? 

The  emptying  of  sewage  into  the  stream  from  which  the 
supply  is  obtained;  surface  w^ater  in  settled  districts  gaining 
entrance  to  the  supply;  sub-soil  water,  after  passing  through 
a  filthy  soil ;  drainage  from  places  of  burial ;  and  water  which 
has  dissolved  poisonous  minerals. 

Describe  the  several  methods  of  purifying  drinking 
water. 

Sedimentation,  occurring  when  collections  of  water  remain 
at  rest  for  a  considerable  time,  removing,  in  part,  at  least, 
suspended  matter. 

Sand  filtration  in  which  the  water  flows  upon  and  through 
prepared  beds  of  sand,  gravel  and  broken  stone,  packed  in 
separate  layers,  removes  from  it  not  only  suspended  matter, 
but  also  dissolved  organic  matter  and  bacteria,  through  the 
action  of  air  (oxygen  in  the  interstices  of  the  filter  material, 
and  the  action  of  saprophytic  bacteria. 

Boiling  w^ater  will  free  it  of  pathogenic  bacteria  and  tem- 
porary hardness,  but  such  water,  after  boiling,  should  be 
aerated  to  fit  it  for  use. 

What  do  you  understand  by  the  "  dry  earth  system  " 
as  applied  to  excrementitious  matter? 

The  container  under  the  privy  seat  contains  the  dry  earth, 
and  after  the  use  of  the  privy  fresh  earth  is  always  to  be 
added  to  the  receptacle.  From  time  to  time  the  contents  are 
removed  and  buried  or  otherwise  disposed  of. 

Contrast  the  incubative  stages  of  measles  and  scarlet 
fever. 

The  stage  of  incubation  in  measles  is  from  one  to  three 


540  HYGIENE. 

weeks  (averaging  12  days)  ;  in  scarlet  fever  from  one  to  eight 
days  (average  3  days). 

Mention  some  of  the  results  of  tobacco  smoking  in 
growing  school  boys  in  respect  to  the  circulation,  air 
passages,  vision  and  mental  application. 

It  depresses  the  circulation  and  produces  palpitation  of 
the  heart.  It  causes  low  grades  of  inflammatory  processes 
in  the  upper  air  passages,  catarrhal  conjunctivitis,  mental 
lethargy,  with  inability  to  sustained  mental  application. 

What  habits  of  school  children  tend  to  produce  myopia? 

Reading  of  small  imperfect  print;  faulty  positions  while 
reading  or  writing  in  which  the  eyes  are  not  far  enough  re- 
moved from  the  page ;  reading  or  writing  in  insufficient  light, 
or  when  fatigued. 

What  should  be  the  proper  temperature  for  a  living^ 
room  in  winter? 

72°  F.  for  old  or  weak  persons;  65°  F.  for  the  young  and 
vigorous. 

What  should  be  the  diet  of  a  child  over  two  years  of  age? 

The  food  should  consist  principally  of  milk  and  bread,  with 
rice,  tapioca,  some  vegetables  of  easily  digestible  character, 
and  sparingly  of  fruit,  preferably  cooked;  but  little  meat 
should  be  allowed,  and  this  preferably  mutton. 

What  hygienic  precautions  should  be  observed  by  a 
pregnant  woman? 

Diet  should  be  nutritious;  clothing  should  be  loose;  mod- 
erate outdoor  exercise  should  be  taken  each  day;  the  marital 
relations  should  cease ;  the  action  of  the  skin  should  be 
stimulated  by  warm  baths.  After  the  sixth  month  the  urine 
should  be  examined  every  few  weeks.  Constipation  should 
be  corrected  by  hygienic  measures  when  possible.  In  late 
pregnancy  the  nipples,  if  necessary,  may  be  developed  hj 
judicious  manipulation. 


HYGIENE.  541 

What  is  the  most  sanitary  way  of  disposing  of  city 
garbage? 

Burn  it,  so  that  all  noxious  vapors  are  also  consumed. 

Describe  the  effects  of  a  cereal  diet. 

Many  writers  assert  that,  as  a  rule,  such  a  diet  produces  a 
lessened  muscular  formation,  with  an  increased  fat  produc- 
tion, and  that  it  also  causes  a  deficient  production  of  red 
hlood  corpuscles,  with  an  accompanying  loss  of  oxidation  and 
tissue  removal ;  but  it  is  probable  that  such  a  diet  is  com- 
patible with  good  health  provided  it  contains  enough  proteids. 

What  is  the  lowest  temperature  of  steam  heat  at  which 
pus  cocci  are  destroyed? 

At  240  degrees  Fahr.  such  organisms  are  killed  in  a  few 
minutes,  while  at  212  degrees  Fahr.  it  requires  an  exposure 
to  steam  of  from  thirty  to  forty  minutes. 

What  physical  training  would  you  recommend  to  a  per= 
son  with  weak  respiration? 

Calisthenic  exercises  without  apparatus  directed  to  increas- 
ing the  extrinsic  and  intrinsic  muscles  of  respiration,  accom- 
panied by  deep  and  slow  breathing.  This  should  be  followed 
by  a  course  of  light,  well-regulated  gymnastic  work,  with 
dumb-bells,  Indian  clubs  ana  wands.  After  a  proper  interval 
of  several  months,  progressively  difficult  mountain-climbing, 
then  running  exercises,  and  finally  general  apparatus  work 
in  a  good  gymnasium  under  proper  instruction. 

Name  three  tests  for  detecting  impurities  in  water. 

Nessler's  test  for  detecting  and  estimating  ammonia. 
Nitrate  of  silver  for  detecting  and  estimating  chlorides. 
Barium  nitrate  for  detecting  and  estimating  sulphates. 

What  is  the  best  sanitary  plan  for  the  disposal  of 
sewage? 

Collect  the  sewage  in  large  tanks  and  to  it  add  lime,  alum 
or  iron  sulphate.     Compress  the  solid  materials  after  their 


542  HYGIENE. 

subsidence  or  precipitation  and  cremate  them.  Allow  the 
liquid  sewage  to  flow  upon  specially  prepared  filter  beds 
which  are  subdrained,  and  the  water  flowing  from  these  sub- 
soil pipes  may  then  pass  into  a  stream  without  great  danger 
of  adding  poisonous  material  or  pathogenic  bacteria. 

What  is  the  temperature  of  tepid  water,  of  hot  water, 
of  boiling  water? 

Tepid  water  75  to  85  degrees  Fahr. 
Hot  water  100  to  110  degrees  Fahr. 
Boiling  water  212  degrees  Fahr. 

What  diseases  are  propagated  by  drinking  water? 
How  can  their  spread  be  prevented? 

Infectious  diseases,  particularly  cholera  and  typhoid  fever; 
diseases  due  to  gastric  and  intestinal  irritation,  as  forms  of 
dyspepsia,  diarrhcea,  dysentery ;  diseases  due  to  animal  para- 
sites; diseases  due  to  metallic  poisons. 

Prohibit  the  use  of  water  containing  any  dissolved  metal. 
Distil  the  water,  or  boil  it  for  at  least  one-half  hour,  thus 
purifying  it. 

Describe  in  detail  the  sanitary  precautions  necessary  in 
typhoid  fever. 

Expose  urine,  stools,  vomitus  and  sputum  for  three  hours 
to  the  action  of  a  solution  of  chlorinated  lime,  of  the  strength 
of  six  ounces  to  a  gallon  of  water,  breaking  up  all  solid 
masses.  Place  all  towels,  napkins  and  bed  linen  in  a  5  per 
cent,  solution  of  carbolic  acid  until  convenient  to  boil  the 
same  for  half  an  hour.  Secure  continuous  ventilation  of  the 
sickroom.  Boil  all  water  and  milk  before  allowing  its  use 
by  the  patient  or  members  of  the  household.  Fumigate  the 
room  and  contents  after  the  patient  leaves  it. 

What  hygienic  precautions  should  be  employed  about 
diphtheria? 

Tsolate  the  patient:  refuse  admission  to  the  sick-room  of 
all    whose   [)respnce   is   not    necessary;   attendants   should   ob- 


HYGIENE.  543 

serve  the  greatest  personal  cleanliness ;  all  secretions  should 
be  collected  upon  cloths  and  burned.  All  articles  should  be 
disinfected  before  being  removed  from  the  sick-room.  Mem- 
bers of  the  household  should  be  quarantined. 

Mention  six  desirable  factors  in  the  location  of  a  resort 
for  consumptives. 

Equable  climate,  high  altitude,  dry  atmosphere, , pure  air. 
abundant  sunshine  and  pine  forests  are  climatic  faetoi-s  for 
consumptives. 

State  the  accepted  belief  in  respect  to  the  limitation  of 
protection  from  vaccination. 

Five  yeai-s,  when  revaccinatiou  should  be  attempted.  Dur- 
ing a  small-pox  epidemic  it  is  advisable  to  revaccinate  all 
individuals  who  have  not  been  vaccinated  within  two  years. 

Mention  some  of  the  adulterations  in  preparations  of 
ground  coffee  for  sale  in  the  shops. 

Chicory,  peas,  roasted  cereals  and  legumes,  date  stones, 
acorns,  sawdust,  etc. 

What  class  of  foods  should  predominate  for  persons 
over  sixty  years  of  age? 

Use  eight-tenths  the  quantity  of  proteids  that  the  vigorous 
adult  requires;  seven-tenths  the  quantity  of  carbohydrates; 
and  one  and  two-tenths  times  the  quantity  of  fats. 

Which  in  your  judgment  is  to  be  preferred  in  vaccina= 
tion,  animal  or  humanized  lymph,  and  why? 

Animal  lymph,  because  in  its  preparation  greater  care  may 
be  taken  to  secure  its  freedom  from  deleterious  additions. 

^    Name  some  of  the  nuisances  dangerous  to  health. 

Gases  and  dust  of  a  poisonous  or  irritating  nature  arising 
from  many  manufacturing  industries.  Collections  of  stag- 
nant watei-,  gai-bage  and  animal  excreta  exposed  to  air;  leak- 
ing drains  or  sewers  saturating  the  soil,  or  allowing  the  escape 
of  gases.  Industries  giving  rise  to  great  noise  or  vibration 
in  tliicklv  settled  eonmninities. 


544  HYGIENE. 

What  is  the  best  means  for  preventing  the  access  of 
sewer  gas  in  dwellings? 

Place  a  trap  or  water  seal  between  the  house  drain  and  the 
sewer  and  provide  an  air  inlet  pipe  to  open  into  the  drain 
pipe  between  this  trap  and  the  house.  A  ventilation  pipe 
should  extend  from  the  house  drain  to  a  point  above  the  roof. 

State  the  ordinary  death  rate  of  each  of  four  cities 
having  respectively  a  population  of  more  than  fifty  thou= 
sand  (50,000). 

Dublin,  39.9 ;  St.  Petersburg.  31 ;  Berlin.  17 ;  Amsterdam, 
17.8  (1897). 

Name  the  diseases  the  predisposition  to  which  is  greatly 
increased  by  the  habitual  use  of  alcohol. 

Diseases  of  the  heart  and  vascular  system,  the  kidneys, 
brain  and  liver,  and  of  the  respiratory  system,  particularly 
pneumonia  and  asthma. 

Mention  methods  to  be  employed  for  preventing  epi= 
demies  of  yellow  fever  in  the  tropics. 

Remove  at  once  to  high  or  new  ground  should  the  disease 
appear.  Cremate  all  those  who  have  died  of  the  disease; 
■disinfect  and  remove  all  filth  and  endeavor  to  destroy  all 
mosquitoes  and  their  larvas  and  other  insect  pests  by  the 
use  of  petroleum,  sub-soil  drainage  of  damp  places,  and  fill- 
ing all  stagnant  pools  with  clean  dirt.  Screen  all  doors  and 
windows. 

Name  four  diseases  that  are  communicable  to  man 
through  cows'  milk. 

Typhoid  fever,  scarlet  fever,  cholera  and  tuberculosis. 

To  what  is*  indigestion  from  excessive  tea  drinking 
attributable.  State  a  formula  for  the  preparation  of 
good  tea. 

The  indigestion  is  caused  chiefly  by  tannin;  also  by  theo- 
bromine. 

Pour  one  pint  of  boiling  water  over  a  dram  of  the  dried 


HYGIENE.  545 

tea  leaves  and  allow  it  to  stand  without  applying  further 
heat  for  five  minutes. 

State  the  advantages  of  cremation  over  earth  burial. 

Complete  destruction  of  specific  disease  germs.  If  crema- 
tion be  well  performed  no  obnoxious  gases  are  given  to  the 
air.  no  gases  of  putrefaction  contaminate  the  air,  and  there 
is  no  danger  of  contaminating  the  wat^r  supply  through 
drainage  from  cemeteries. 

What  are  the  respective  merits  of  cotton,  wool  and  silk 
when  used  as  underwear? 

In  a  variable  climate  wool  is  preferable  because  from  a 
larger  amount  of  air  enclosed  in  its  texture  it  acts  as  a  good 
non-conductor  of  heat,  retaining  the  body  temperature.  As 
wool  is  hygroscopic  it  readily  absorbs  moisture  from  which 
it  parts  slowly,  so  preventing  surface  chill  of  the  individual 
by  too  rapid  evaporation.  Next  in  order  to  retain  the  heat 
of  the  body  we  rank  silk,  and  least  valuable  for  the  retention 
of  body  heat  is  cotton.  If  it  be  our  purpose  to  supply  a  cool 
garment  we  would  of  course  reverse  this  order  of  arrange- 
ment. 

If  a  chemical  analysis  of  water  revealed  the  presence 
of  nitrites  and  nitrates,  would  this  condemn  it  for  drink= 
ing  purposes?     If  so,  why? 

Yes.  particularly  if  nitrites  be  present.  Organic  matter, 
particularly  sewage,  is  converted  first  into  nitrites,  and  these 
into  nitrates  through  the  action  of  bacteria  in  the  soil.  These 
salts  would,  therefore,  indicate  a  former  pollution  of  the 
watei-  with  probably  some  of  that  polluted  material  still  in 
the  water.  If  nitrates  only  are  present,  and  it  can  be  shown 
that  the  organic  matter  is  of  a  vegetable  origin  only,  the  water 
need  not  be  condemned. 

To  what  diseases  are  negroes  comparatively  insuscep- 
tible? In  the  Middle  States  to  what  diseases  are  negroes 
more  prone  than  whites? 

Dysentery,  yellow   fever,   malaria  and  diseases  incident  to 
35 


546  HYGIENE. 

exposure  to  summer  heat.  Negroes  are  more  prone  thani 
whites  to  contract  small-pox,  diseases  of  the  respiratory  tract, 
fibroid  tumoi*s,  keloid  growths  and  venereal  diseases. 

Give  a  medical  and  hygienic  plan  for  the  inspection  of 
immigrants  who  have  just  arrived  at  a  seaport. 

Examine  the  "Bill  of  Health"  and  clinical  records  of  all 
cases  treated  during  the  voyage  and  the  lists  of  passengers, 
crew  and  manifests,  and,  if  desirable,  the  ship's  log.  Have- 
crew  and  passengers  mustered  and  compared  with  the  lists, 
investigating  any  discrepancies  and  make  a  careful  examina- 
tion of  both  crew  and  passengera.  If  a  case  of  infectious 
disease  has  occurred  during  the  voyage,  disinfect  all  exposed 
baggage  and  freight  and  detain  such  members  of  the  crew 
and  passengers  as  have  been  exposed  until  the  incubation* 
period  of  the  disease  has  passed. 

What  conditions  of  ill  health  make  residence  in  high 
altitudes  dangerous?     Why? 

Chronic  Bright 's  disease,  disease  of  the  heart,  emphysema, 
and  old  age.  High  altitudes  occasion  increased  respiratory 
effort  from  the  rarified  condition  of  the  atmosphere,  causing 
increased  heart  action,  and  a  lessened  perspiratory  function. 

State  the  physical  conditions  that  make  the  practice  of 
taking  of  hot  baths  inadvisable. 

Acute  inflammatory  diseases,  tuberculosis,  organic  diseases- 
of  the  heart  and  brain,  aneurysm,  cancer,  and  all  diseases  in. 
which  stimulation  of  the  circulation  is  to  be  avoided. 

State  some  of  the  sequelae  of  (a)  over=strain,  (b)  over- 
exertion, (c)  over=training. 

(a)  Parting  of  continuity  of  osseous,  ligamentous,  muscu- 
lar or  blood-vessel  structure  leading  to  fractures,  dislocations, 
rupture  of  muscles,  hernia,  rupture  of  heart  muscle,  disease 
of  valves  of  heart  or  apoplexy. 

(b)  May  produce  same  conditions  as  overstrain  and  in. 
addition  cause  general  muscular  relaxation,  dyspnea,  syn- 
cope, etc. 


HYGIENE.  547 

(c)  Loss  of  appetite  and  of  muscular  power,  successive 
crops  of  boils  appear,  individual  loses  power  of  concentration 
of  thought,  and  digestive  disturbances  occur. 

What  constitutes  hard  water  and  soft  water? 

"Hardness  is  the  capacity  a  water  has  for  decomposing 
soap,  and  depends  on  the  amount  of  salts  of  magnesia  and 
calcium  in  solution."     (Harrington.) 

Soft  water  contains  little  or  no  dissolved  salts  and  rapidly 
forms  a  lather  with  soap. 

Mention  the  dangers  of  excessive  shade  about  dwellings. 

Excessive  shade  interferes  with  the  free  movement  of  air, 
prevents  penetration  of  the  sun's  rays,  promotes  dampness 
which  is  given  off  to  the  air  by  evaporation.  It  exerts  a  de- 
pressing mental  action,  promotes  the  growth  of  fungi  and 
bacteria,  and  prevents  the  aspirating  action  of  heat  from  the 
sun  upon  air  and  moisture  in  the  soils. 

What  is  milk  sterilization?     How  is  it  performed? 

Destruction  of  micro-organisms  in  the  milk  by  heat.  By 
continuous  heating  of  the  milk,  under  pressure,  for  two 
hours  at  248°  F. 

State  the  objections  usually  advanced  against  vaccina- 
tion as  a  preventive  of  smalUpox. 

It  is  urged  that  it  fails  to  protect  from  small-pox  (which 
is  false),  that  it  may  produce  blood-poisoning,  that  constitu- 
tional diseases  like  syphilis,  scrofula,  etc.,  may  be  introduced 
by  the  vaccine  virus,  or  in  the  operation.  Also  that  tetanus 
may  result,  and  that  it  is  not  right  to  deliberately  inoculate 
a  healthy  person  with  the  virus  of  vaccinia  or  of  any  disease. 

On  what  generally  accepted  theory  are  toxins  used  for 
the  prevention  and  cure  of  disease? 

That  their  presence  in  the  system  renders  the  blood  no 
longer  able  to  support  the  lives  of  bacteria  that  occasion  such 
toxins. 


548  HYGIENE. 

What  infectious  diseases  may  be  due  to  impure  drink= 
ing  water? 

Tj^plioid  fever,  malarial  fevers,  cholera,  relapsing  fever, 
dysentery,  parasitic  diseases. 

Define  humidity  of  the  atmosphere.  Why  should  a 
humid  atmosphere  cause  rheumatic  persons  and  persons 
suffering  with  the  gout  increased  sensitiveness? 

The  term  humidity  refers  to  vapor  of  water  in  the  air.  An 
increased  humidity  increases  sensitiveness  of  gouty  and  rheu- 
matic patients  by  decreasing  elimination  from  the  skin  of 
excretory  organic  matters  and  uric  acid  derivatives  and  thus 
leading  to  retension  of  such  poisons  in  the  system. 

What  constitutes  a  thorough  meat  inspection?  How 
should  an  inspection  of  milk  be  conducted? 

Meat  should  be  inspected  within  24  hours  after  the  animal 
is  killed.  The  following  points  are  noted :  The  quantity  of 
bone,  for  which  17  to  20  per  cent,  is  to  be  allowed.  The 
quantity  and  character  of  the  fat,  noting  its  color,  consis- 
tency, and  taste.  Condition  of  the  flesh.  Condition  of  the 
marrow.  Examination  of  the  lungs,  liver,  kidneys  for  detec- 
tion of  infectious  disease  manifestations.  A  microscopical 
examination  of  the  flesh  for  detection  of  bacteria  of  path- 
ogenic character,  trichina,  tape-worm  or  other  parasites. 
"Where  possible,  it  is  well  to  investigate  the  surrounding's  in 
which  the  animal  has  lived  and  the  methods  employed  for 
storage  and  refrigeration. 

An  inspection  of  milk  takes  cognizance  of  its  specific  grav- 
ity, color,  quantity  of  cream,  presence  of  preservatives,  pres- 
ence or  absence  of  dilution,  or  addition  of  coloring  matter, 
determination  of  total  solids,  of  quantity  and  quality  of  ash, 
of  fats,  casein,  lactose.  The  microscopical  and  bacteriological 
examinations  are  performed  and  finally  an  examination  is 
made  of  the  source,  storage  and  distributing  methods. 


HYGIENE.  549 

How  is  bubonic  plague  transmitted,  and  what  is  the 
best  method  of  eradicating  the  disease? 

Chiefly  by  rats,  and  to  some  extent  by  fl€as,  dogs,  cats, 
rabbits,  etc.,  fomites,  and  infected  food.  Enters  the  body 
through  the  skin,  alimentary  or  respiratory  tract.  Eradicated 
by  rigid  isolation  of  patient,  quarantine  of  houses,  killing  all 
animals  suspected  or  proved  to  be  infected.  Rigid  sanitation. 
Disinfect  clothing,  bed  linen,  vomitus  and  stools. 

State  in  detail  the  necessary  hygienic  precautions  in 
tuberculosis. 

Room  to  be  stripped  of  unnecessary  objects,  especially 
where  dust  may  lodge.  Patient  should  sleep  alone,  and 
avoid  kissing  and  other  direct  contact  with  others.  Rigid 
use  of  sputum  cup  or  paper  kerchief,  which  should  be  boiled 
or  burned.  Disinfection  of  articles  used  by  patient,  as  dishes, 
body  linen,  bed  clothing.  Restrain  patient  from  frequenting 
closed  rooms  or  places  where  people  gather  in  numbers. 

What  are  the  hygienic  advantages  of  the  cold  and  hot 
bath? 

Cold  bath :  tonic  to  skin,  increases  peripheral  circulation, 
lessens  susceptibility  to  cold  and  climatic  changes,  and  acts  as 
a  tonic  to  the  nervous  system,  aids  general  metabolism. 

Hot :  Cleanses  pores,  carries  off  waste  products,  relaxes 
nervous  tension,  induces  sleep. 

What  are  the  relative  advantages  and  disadvantages  of 
artificial  lighting  by  electricity,  gases,  oils  and  candles? 

(a)  Evenness  of  light  with  (incandescent  lights)  no  con- 
sumption of  oxygen.     Cost  not  excessive. 

(b)  Gives  off  products  of  combustion,  burns  up  O,  and  gives 
wavering  light. 

(c)  Causes  smoke  and  soot.     Burns  up  0. 

(d)  Dim,  flickering  light.  Unclean.  Expensive  and  in- 
sufficient.    Preference  of  selection  in  order  named. 

What  hygienic  principles  must  be  observed  by  the  well 


550  HYGIENE. 

members  of  a  stricken  household  to  prevent  the  spread  of 
disease? 

Avoid  contact  with  the  patient;  disinfect  body  and 
clothing  if  contact  occurs.  Sprays  and  gargles.  Rigid  per- 
sonal cleanliness  and  attention  to  personal  habits,  with  avoid- 
ance of  all  excesses.  Change  of  clothing  before  mingling 
with  the  public. 

State  the  best  means  for  the  prevention  of  infection  of 
secondary  syphilis. 

Rigid  personal  cleanliness  of  hands,  mouth  and  body  of 
patient.  Individual  dishes,  towels,  etc.  Avoid  kissing  or 
handling  other  persons,  particularly  around  mucous  mem- 
branes. Use  separate  bathing  materials  whenever  possible. 
Body  linen  to  be  disinfected  and  washed  separately.  No 
sexual  intercourse. 

Give  methods  of  prevention  of  infection  of  tuberculosis. 

Collect  and  destroy  all  sputa  and  excreta.  Have  patient 
hold  hand  or  paper  over  face  while  coughing.  Avoid  fre- 
quenting of  crowded  rooms.  Sleep  alone  in  a  room  as  nearly 
bare  as  possible,  so  as  to  limit  the  formation  and  collection 
of  dust.  Obtain  the  greatest  amount  of  sunlight  available, 
and  keep  constant  current  of  air  in  room,  exposing  all  mov- 
able articles  to  sunlight  at  frequent  intervals.  Disinfect  all 
utensils  and  clothing  used  by  patient.  Burn  articles  that 
are  of  no  further  use. 

State  what  hygienic  and  sanitary  measures  barbers 
should  be  compelled  to  adopt. 

To  have  a  clean  shop  with  abundant  sunlight,  avoiding  dust 
and  draperies.  Use  leather  chairs.  Regular  cleansing  of 
hands.  Use  of  outside  clothing  that  can  be  easily  washed. 
Careful  toilet  of  mouth.  Individual  articles  for  patrons. 
Routine  sterilization  of  cups,  brushes,  etc.  Exclude  employees 
known  to  be  suffering  from  syphilis  or  other  contagious 
disease. 


HYGIENE.  551 

What  hygienic  measures  should  you  adopt  in  infant 
feeding? 

(a)  Maternal:  Cleanliness  of  breasts  and  hands.  Frequent 
bathing.     Attention  to  general  health. 

(b)  Infant:  Cleanse  mouth  with  mild  antiseptic.  Feed  for 
15  minutes  every  two  hours  at  first,  increasing  time  and  inter- 
val as  indicated.  For  artificial  feeding,  procure  a  good  milk 
that  comes  from  an  even  source.  Sufficient  numbers  of 
hottles  and  nipples  to  permit  a  thorough  cleansing  between 
feedings.  Even  temperature  of  food.  No  warmed-over  food 
in  bottles.  Holding  bottle  for  child  too  young  to  handle  it, 
and  see  that  it  gets  milk  and  not  air.  Watch  stools  for  evi- 
dence of  mal-assimilation,  and  correct  proportion  of  fats,  etc., 
as  indicated. 

Describe  the  proper  hygienic  measures  in  a  case 
of  typhoid  fever  in  a  private  house  to  prevent  transmis= 
sion. 

Isolate  the  patient  in  a  quiet  room  devoid  of  extra  furnish- 
ings. Adjoining  room  to  be  used  by  nurse.  Disinfect  all 
dishes,  bed  clothing,  etc.,  that  have  been  in  contact  with  the 
patient.  Disinfect  stools,  urine,  vomit.  Routine  wash- 
ing of  hands  by  nurse  and  doctor  after  handling  patient. 
Rigid  toilet  of  mouth  for  nurse  and  patient.  Cleanse  the 
finger  nails.  Screen  the  windows  and  doors  to  prevent  en- 
trance of  flies.  Examine  the  water  supply  and  sewerage  of 
the  house.     Disinfection  of  toilet  rooms  or  sewers. 

State  the  care  to  be  observed  in  order  to  obtain  a  pure 
milk  from  a  cow  to  the  consumer. 

Have  stable  in  an  elevated  location,  and  favor  drainage  of 
all  fluids.  Troughs  for  manure.  Healthy  farm  hands. 
Thorough  cleansing  of  cans  and  utensils.  Wash  the  cow's 
teats  with  mikl  antiseptic.  Cover  cans  quickly  to  prevent 
dust.  Keep  out  flies.  Store  cans  in  cool  milk  house.  Have 
pure  water  for  general  purposes.  Wash  and  sterilize  milk 
bottles,  and  have  clean  siphon  apparatus  for  filling  same.  Air- 
tight caps  for  bottles.     Handle  them  as  little  as  possible  before 


552  HYGIENE. 

delivery  to  the  consumer.     Routine  frequent  bacteriological 
examination  of  milk. 

What  precautions  are  necessary  to  prevent  contagion 
in  ophthalmia  neonatorum? 

If  the  mother  is  known  to  have  gonorrhea,  give  an  ante- 
partum douche.  Cleanse  the  eyes  as  soon  as  head  is  born. 
Use  Crede  Method,  i.  e.  instill  one  drop  of  a  2%  solution  of 
silver  nitrate,  into  each  eye,  followed  later  by  normal  saline. 
If  only  one  eye  is  affected,  place  shield  over  opposite  eye  for 
protection.  Destroy  all  materials  that  have  been  used  in 
treatment  of  infection.  Rigid  antiseptic  precautions  by  nurse 
and  doctor. 

Describe  two  methods  for  the  sanitary  disposal  of  sew= 
erage  and  garbage. 

(a)  Pneumatic  system.  Sewerage  is  conducted  by  gravity^ 
through  suitable  drains  to  convenient  stations  or  tanks,  and 
then  forced  by  compression  to  irrigation  field,  or  to  place  of 
ultimate  disposal. 

(b)  Earth  closets.  Remove  at  frequent  intervals  by  drains, 
running  at  a  proper  distance  from  the  house.  Add  dry  sifted 
earth,  about  twice  the  bulk  of  the  dejecta.  If  any  known 
aliment-ary  disease  exists,  add  chlorinated  lime,  or  sulphate 
of  iron  to  disinfect. 

Of  what  value  is  a  knowledge  of  the  period  of  incubation 
in  a  given  disease? 

So  that  a  definite  duration  of  quarantine  may  be  established 
for  those  who  have  been  exposed  to  the  infection. 

What  are  the  benefits  of  the  cold  air  treatment  of  lobar 
pneumonia? 

The  patient  receives  an  abundance  of  pure  air,  lessens  nerv- 
ous symptoms,  permits  sleep,  and  conserves  the  body  strength.. 

Describe  the  physical  appearance  of  good  milk  in  bulk. 

It  should  be  opaque,  of  clear  ivory-white  color,  no  peculiar- 
smell  or  taste,  with  no  deposit  on  standing.  It  should  not 
show  change  in  appearance  or  taste  upon  boiling,  except  a 
slight  scum  on  the  surface  due  to  coagulated  albumin. 


SURGERY. 

Define  peritonitis.  State  three  ways  in  which  the  peri  = 
toneum  may  be  invaded  by  bacteria. 

By  peritouitis  is  meant  an  inflammation  of  the  peritoneum. 
Bacteria  may  invade  the  peritoneum  through  the  wall  of  the 
intestine,  through  a  wound  in  the  abdominal  wall,  or  through 
a  perforating  ulcer  of  the  stomach. 

What  is  the  treatment  for  stenosis  of  the  lachrymal 
duct? 

Dilatation  by  means  of  lachrymal  probes.  The  passage  of 
the  larger  probes  is  preceded  by  division  of  the  lower  canali- 
culus. If  the  stenosis  is  simply  due  to  tumefaction  of  the 
mucous  membrane  (as  in  the  new-born)  it  may  yield  to 
medicinal  agents. 

What  are  the  causes  of  ischio^rectal  abscess? 

Infection  of  the  iscliio-rectal  areolar  tissue  with  pyogenic 
organisms  from  the  perineum  or  rectum,  injuries  to  the  peri- 
neum or  rectum,  and  exposure  to  cold  or  wet.  Suppuration 
in  the  ischio-rectal  fossa  may  also  be  due  to  disease  of  adja- 
cent or  distant  structures  (sacro-iliae  or  hip  joints,  pelvic 
bones,  spine,  prostate). 

(Jive  an  operation  for  excision  of  the  tongue  for  car= 
cinoma. 

Kocher's  oi)eration.  After  all  aseptic  precautions  have 
been  carried  out,  both  submaxillary  triangles  are  opened,  the 
lymphatic  glands  removed,  and  the  lingual  arteries  ligated. 
.Mthough  the  remainder  of  the  operation  may  be  immediately 
performed  it  is  bettor  to  postpone  it  for  ten  days  or  two 
weeks.     Tbo  lower  lip   is  then  divided  by  a  median  incision 


554  SURGERY. 

which  extends  downward  to  the  hyoid  bone.  The  mandible 
is  sawn  through  just  to  one  side  of  the  median  line,  the  two 
halves  widely  separated,  and  the  tongue  transfixed  and  drawn 
well  forward  by  a  loop  of  silk.  The  oral  mucous  membrane  is 
incised  as  close  to  the  jaw  as  possible,  the  hyoglossi  and  stylo- 
glossi divided  and  their  cut  surfaces  cauterized.  The  glosso- 
phryngeal  nerve  is  also  cut.  The  mucous  membrane  far  back 
over  the  dorsum  of  the  tongue  is  next  incised  and  the  muscu- 
lar mass  of  the  tongue  divided  by  the  thermocautery  well  back 
of  the  limits  of  the  growth.  A  thin  layer  of  xeroform  should 
be  rubbed  into  the  cut  surfaces,  and  the  two  halves  of  the 
mandible  wired  together.  The  median  incision  should  be 
sutured  except  at  a  point  just  above  the  hyoid  bone  where  a 
small  strip  of  xeroform  gauze  is  inserted  for  drainage. 

How  should  ankylosis  of  the  jaw  be  treated? 

By  division  of  the  neck  of  condyle,  by  excision  of  condyle, 
removal  of  the  vertical  ramus  as  far  as  the  alveolar  border,  or 
by  the  excision  of  a  wedge  of  bone  (apex  toward  alveolar 
border)  from  the  neighborhood  of  the  angle,  and  the  estab- 
lishment of  an  artificial  joint  in  this  situation  (Esmareh's 
operation).  Excision  of  the  condyle  and  Esmarch's  operation 
are  the  mea.sures  usually  employed. 

How  should  hemorrhage  from  the  liver,  occurring  in  the 
course  of  an  operation,  be  controlled? 

By  tamponing  with  iodoform  gauze,  by  the  thermo-cautery, 
by  ligature,  and  by  suture. 

Describe  Pott's  fracture  of  the  lower  extremity. 

By  Pott's  fracture  is  meant  a  fracture  of  the  fibula  about 
three  inches  above  the  tip  of  the  malleolus.  Dependent  upon 
the  amount  of  violence,  there  may  co-exist  one  or  more  of  the 
tollowing  lesions:  1.  Kupture  of  the  internal  lateral  ligament; 
2.  Tearing  off  of  the  internal  malleolus;  3.  Fracture  of  the 
external  portion  of  the  inferior  articular  surface  of  the  tibia. 
The  foot  is  practically  always  everted,  and  shows  a  tendency 
to  slip  backward.     There  are  points  of  tenderness  over  the 


SURGERY.  555 

lines  of  fracture,  the  foot  may  be  moved  from  side  to  side  in 
the  widened  tibio-fibular  mortise,  and  crepitus  may  be  ob- 
tained. 

Give  the  symptoms  and  treatment  of  section  of  the 
median  nerve. 

If  divided  just  above  the  wrist  there  will  be  anesthesia  over 
the  radical  side  of  the' palm,  over  the  palmar  aspect  of  the 
thumb,  index,  middle,  and  half  of  the  ring  fingers,  and  over 
the  dorsal  aspect  of  the  terminal  phalanges  of  the  same 
fingers.  There  will  be  paralysis  of  the  outer  group  of  the 
.short  muscles  of  the  thumb  (abductor,  opponens,  and  outer 
half  of  flexor  brevis  poUicis),  as  a  result  of  which  "  opposi- 
tion" is  impaired,  the  thumb  remaining  extended  by  the  side 
of  the  fingers.  The  outer  lumbricals  are  also  paralyzed,  caus- 
ing loss  of  power  of  flexion  of  the  index  and  middle  fingers 
at  the  metacarpo-phalangeal  articulation.  If  divided  at  the 
bend  of  the  elbow  or  in  the  arm,  in  addition  to  the  previously 
mentioned  symptoms,  there  will  be  loss  of  pronation  (paralysis 
of  flexor  carpi  radialis) ,  loss  of  power  in  the  hand-grasp,  par- 
ticularly on  the  radial  side,  with  probable  hyperextension  of 
the  wrist  (paralysis  of  flexor  longus  poUicis,  of  the  flexor 
sublimis,  and  of  the  outer  half  of  the  flexor  profundus 
cligitorum),  and  paralysis  of  the  palmaris  longus. 

Treatment :  After  all  aseptic  precautions  have  been  carried 
out,  the  ends  of  the  nerve  are  to  be  sought  in  the  wound  and 
approximated  by  sutures  of  the  finest  chromicized  cat-gut. 
One  or  more  sutures  should  pass  through  the  nerve  and  the 
remainder  merely  through  the  sheath.  A  fine  Hagedorn 
needle  or  a  domestic  sewing-needle  without  cutting  edges 
should  be  employed.  If  difficulty  is  encountered  in  bringing 
the  ends  together,  the  wrist  and  elbow  joints  are  flexed  to  a 
right  angle,  and  subsequently  maintained  in  this  position  by 
a  fixed  dressing. 

'  State  the  constitutional  effects  and  give  the  treatment 
of  burns. 

Stage  of  shock  or  collap.se :  The  surface  of  tlie  body  is  cov- 


556  SURGERY. 

ered  with  a  cold  aud  elarainy  sweat,  the  temperature  is  sub- 
normal, the  pulse  is  rapid  aud  feeble,  aud  the  respirations 
are  quick  and  shallow.  The  tongue  is  dry,  the  patient  ex- 
periences great  thrist,  vomiting  often  occurs,  and  the  urine 
and  feces  may  be  passed  involuntarily.  There  is  congestion 
of  the  internal  viscera,  particularly  those  in  relation  with 
the  portal  system. 

Stage  of  reaction:  Symptoms  of  septic  traumatic  fever, 
with  special  symptoms  dependent  upon  intiammatory  alfec- 
tions  of  the  internal  organs  (meningitis,  peritonitis,  enteritis, 
duodenal  ulcer) . 

Stage  of  exhaustion  or  recovery:  Symptoms  of  septicemia 
or  pyemia  may  make  their  appearance.  Death  may  occur 
from  inflammation  of  the  lungs  or  pleura  or  from  auiyloid 
degeneration  of  the  viscera.  If  repair  is  healthy,  no  abnormal 
constitutional  condition  follows  the  second  stage  excepting 
a  certain  amount  of  asthenia. 

Local  treatment :  Superficial  burns  without  vesication  sim- 
ply require  a  dusting  powder  such  as  flour  or  boric  acid. 
If  vesication  is  present,  the  blisters  should  be  opened  aseptic- 
ally,  and  the  part  enveloped  in  lint  soaked  in  carron  oil 
(equal  parts  of  linseed  oil  and  lime  water,  with  one  part  of 
oil  of  eucalyptus  in  ten  of  the  mixture),  or  in  aqueous  solu- 
tions of  picric  acid  (1-200).  In  deep  burns  the  part  should 
be  cleansed  as  thoroughly  as  possible,  and  covered  by  a 
moist  antiseptic  dressing  until  the  sloughs  separate,  when  the 
resultng  granulating  surface  may  be  treated  on  general  prin- 
ciples. During  the  process  of  cicatrization,  great  care  must 
be  exercised  lest  deformity  result  from  contraction.  Such 
deformity  maj^  be  prevented  by  the  use  of  splints  or  weights, 
and  particularly  by  the  employment  of  Thiersch's  method  of 
skin-grafting.  M^hen  a  limb  has  been  hopelessly  charred  it  is 
best  to  amputate  in  healthy  tissue  at  the  earliest  favorable 
opportunity. 

Constitutional  treatment:  Promote  reaction  by  external 
heat,  hypodermatic  injection  of  strychnine,  and  some  warm, 
stimulatinu'  fluid  given  by  the  mouth  or  rectum.     Intravenous 


SURGERY.  557 

injection  of  warm  saline  solution  is  advisable  in  some  cases. 
If  the  pain  is  severe,  opium  may  be  administered.  During 
the  second  stage  the  secretions  should  be  kept  active,  and 
the  patient  placed  on  a  liquid  nutritious  diet.  In  the  third 
stage,  tonics,  stimulants,  and  nutritious  easily-digested  food 
are  indicated. 

Name  five  of  the  principal  complications  of  gonorrheal 
urethritis  in  the  male. 

Lj'^mphangitis,  bubo,  prostatitis,  cystitis,  and  epididymitis. 

What  are  the  indications  for  exsection  of  the  knee= 
joint? 

Tubercular  disease,  disorganization  of  joint  after  pyemia 
or  osteo-arthritis,  old,  neglected  cases  of  infantile  paralysis 
where  there  is  a  fiail-like  limb  (Wright),  certain  cases  of 
compound  fracture  (particularly  after  gunshot  wounds),  and 
deformity  due  to  fibrous  or  bony  ankylosis  in  a  bad  position. 

What  is  the  treatment  of  depressed  fracture  of  the 
skull? 

All  such  cases  should  be  trephined  under  aseptic  pre- 
cautions, and  the  exact  amount  of  intracranial  mischief  deter- 
mined. The  depressed  fragment  may  then  be  elevated,  and 
any  pressure  upon  the  brain  immediately  relieved. 

Give  the  indications  for  the  removal  of  the  mammary 
;;land. 

(Carcinoma,  sarcoma,  diffuse  hypertrophy,  ditt'use  septic  or 
tubercular  disease,  and  certain  eases  of  interstitial  ma.stitis. 

What  is  Paget's  disease  of  the  nipple?  State  the  special 
significance  of  its  occurrence. 

Paget's  disease  of  the  nipple  is  said  by  some  to  be  a  form 
of  eczema,  but  according  to  high  authority,  it  is  an  intra- 
epidermoid  carcinoma  which  has  invaded  both  the  milk-ducts 
and  the  .skin.  The  nipple  affected  has  an  excoriated,  bright 
red  surface,  which  discharges  a  yellowi.sh  viscid  fluid.  The 
excoriation  spreads  until  the  entire  areola  is  involved  and  the 
patient  complains  of  burning  pain. 


558  SURGERY. 

The  special  significance  of  the  occurrence  of  the  disease  is 
that  carcinoma  is  already  present  in  the  breast  and  that  the 
only  treatment  should  be  the  modern  operation  for  removal 
of  the  breast  and  exploraton  of  the  axilla  in  every  case. 

What  are  the  indications  for  incising  the  membrana 
tympani? 

The  evacuation  of  serum,  mucus  or  pus  from  the  tympanum, 
the  relief  of  anomalies,  of  tension  of  the  drum  membrane, 
and  to  gain  access  to  the  tympanum  for  the  purpose  of  re- 
moving intratympanic  polypi  or  dividing  synechiae. 

Describe  the  steps  in  the  treatment  of  a  scalp  wound. 

Hemorrhage  is  to  be  controlled  by  pressure  or  ligation.  The 
scalp  should  be  shaved  for  a  distance  of  several  inches  from 
the  margins  of  the  wound.  If  the  wound  is  very  extensive 
the  entire  scalp  should  be  shaved.  All  foreign  substances  are 
removed  from  the  wound,  and  it  is  disinfected  with  antiseptic 
solutions  (bichloride  1-1000).  The  wound  should  now  be 
sutured  with  silkworm  gut  and  a  moist  bichloride  dressing 
(1-4000)  applied.  If  the  wound  subsequently  shows  signs  of 
infection,  one  or  more  of  the  sutures  should  be  immediately 
removed,  the  wound  again  disinfected,  packed  with  iodoform 
gauze,  and  allowed  to  granulate.  After  granulation  has  oc- 
curred it  may  be  closed  by  secondary  sutures.  Primary  suture 
should  be  the  routine  treatment  in  almost  every  case. 

How  can  the  danger  of  ankylosis  be  averted  after  in= 
jury  to  a  joint? 

By  surgical  cleanliness,  rest,  and  the  early  employment  of 
massage  and  passive  motion. 

What  are  the  symptoms  of  morbus  coxae  in  its  different 
stages? 

First  stage :  Pain  in  affected  joint  and  corresponding  knee, 
limping  or  shuffling  gait,  more  or  less  fixation  of  the  joint 
from  muscular  rigidity,  the  knee  is  slightly  flexed  and  the 
limb  is  usually  abducted.     Swelling  is  most  marked  in  the 


SURGERY.  559 

arthritic  variety  of  the  disease.  Heat  and  redness  are  usually 
absent  on  account  of  the  distance  of  the  articulation  from 
the  surface. 

Second  stage :  Pain  is  more  acute,  the  child  limps  decidedly, 
atrophy  of  the  thigh  is  apparent,  and  rigidity  of  the  abductors 
is  marked.  The  limb  is  somewhat  flexed,  abducted,  everted, 
and  apparently  lengthened.  Flattening  of  the  buttocks  is 
present,  and  the  sulcus  between  the  nates  is  no  longer  vertical, 
but  inclined  toward  the  aft'ected  side.  Full  extension  and 
abduction  are  restricted,  "starting"  pains  are  present. 

Third  stage :  Flexion  is  marked,  adduction  is  present,  and 
shortening  is  observed  which  is  apparent  at  first,  but  sub- 
sequently actual.  The  whole  extremity,  including  the  gluteal 
region,  is  greatly  atrophied.  If  the  diseased  leg  is  extended 
so  that  the  knee  touches  the  table,  the  lumhar  curve  becomes 
so  pronounced  that  there  is  frequently  room  for  the  arm  of 
the  surgeon  between  it  and  the  table.  The  rima  natium  is 
inclined  away  from  the  affected  side  and  there  is  a  compen- 
satory double  lateral  curvature  of  the  spine.  Abscesses  may 
form  and  point  at  the  outer  side  of  the  thigh  below  the  tro- 
chanter (disease  of  head  of  femur),  in  the  pubic  region 
f disease  of  acetabulum),  or  in  the  gluteal  region  (either 
form).  If  the  abscess  points  above  Poupart's  ligament  it  is 
intrapelvic,  if  below,  extrapelvic. 

What  is  hydrophobia  and  how  is  it  treated? 

Hydrophobia  is  an  acute  infectious  disease  resulting  from 
the  inoculation  of  a  specific  virus  from  an  animal  suffering 
from  rabies. 

Prophylactic  treatment:  Most  important,  as  no  curative 
treatment  exists.  The  wound,  if  made  by  a  supposedly  rabid 
animal,  should  be  freely  excised  or  thoroughly  cauterized 
(actual  cautery  is  best,  caustic  potash,  fuming  nitric  acid). 
If  this  cannot  be  done  at  once,  constriction  should  be  applied 
upon  the  proximal  side  of  the  wound.  The  wound  resulting 
from  excision  should  be  thoroughly  disinfected  and  sutured 
or  treated   openly,    according  to  the  exigencies   of  the   case. 


560  SURGERY. 

Prophylactic  luoculations  with  emulsions  of  the  dried  spinaJ 
cords  of  rabbits  infected  with  hydrophobia  (Pasteur  treat- 
ment) should  be  made  in  all  cases  where  the  animal  inflicting 
the  bite  was  rabid,  and  in  those  cases  in  which  it  can  not  be 
proven  that  the  animal  did  not  have  rabies.  The  prophy- 
lactic treatment  also  includes  the  muzzling  of  dogs  and  the 
rigid  maintenance  of  a  dog  quarantine. 

Palliative  treatment :  The  free  use  of  morphine,  chloral 
and  chloroforai.  The  patient  is  kept  in  a  darkened  room, 
and  all  external  sources  of  irritation  are  removed.  Nutritive 
enemata  may  be  given. 

How  would  you  perform  tracheotomy? 

The  patient  is  placed  in  the  doi'sal  position,  with  the  head 
extended,  and  a  cylindric  cushion  placed  beneath  the  neck. 
An  assistant  holds  the  head  so  that  the  median  line  of  the 
face  will  correspond  to  the  median  line  of  the  neck.  After 
all  aseptic  precautions  have  been  observed  and  the  various 
landmarks  (pomum  Adami.  cricoid  cartilage)  located,  an 
incision,  two  and  a  half  inches  in  length,  is  made  in  the  median 
line,  terminating  at  the  lower  border  of  the  thyroid  cartilage. 
This  incision  is  made  from  below  upward,  and  divides  the 
skin  and  superficial  fascia.  The  anterior  jugular  veins  lying 
to  either  side  of  the  median  line  should  be  avoided  by  cutting 
between  them  and  drawing  them  aside.  The  deep  cervical 
fascia  is  now  divided,  the  interval  between  the  pretracheal 
muscles  recognized,  and  the  wound  deepened  by  blunt  dissec- 
tion. The  pretracheal  fascia  is  now  divided,  and  the  isthmus 
of  the  thyroid  gland  drawn  downward.  After  hemorrhage 
has  been  checked  and  the  tracheal  rings  clearly  exposed,  the 
trachea  is  steadied  by  a  tenaculum,  and  two  or  three  rings 
are  divided  from  below  upward  with  a  narrow-bladed  knife. 
The  edges  of  the  tracheal  wound  ai-e  then  held  apart  and  the 
tracheal  tube  inserted. 

What  are  the  symptoms  of  septic  surgical  fever? 

There  is  a  sharp  rise  of  temperature  24  or  36  liours  after 


SURGERY.  561 

the  operation  or  injury.  The  skin  is  hot  and  dry,  the  pulse 
is  rapid,  and  the  tongue  is  coated.  Constipation,  anorexia, 
local  heat,  thirst,  restlessness  and  delirium  are  present.  The 
urine  is  scantj-  and  highly  colored.  The  lips  of  the  wound  are 
red,  swollen  and  tender.  The  temperature  falls  with  the 
advent  of  suppuration. 

What  are  the  indications  for  trephining  in  fractures  of 
the  skull? 

All  punctured  fractures,  all  compound  depressed  fractures, 
all  simple  depressed  fractures,  and  all  cases  in  which  there  are 
syiuptoius  of  intracranial  damage. 

Mention  the  different  kinds  of  displacement  in  fracture. 
In  what  directions  does  the  line  of  fracture  extend  in  the 
case  of  the  long  bones? 

Varieties  of  displacement:  Angular,  transverse,  longitud- 
inal and  rotary. 

Directions  of  line  of  fracture :  Transverse,  oblique,  spiral, 
longitudinal,  toothed.  V-shaped,  and  T-shaped. 

What  general  principles  govern  the  diagnosis  of  a 
tumor? 

The  age  and  sex  of  the  patient,  hereditary  influence,  the 
history  of  previous  trauma,  the  location,  shape,  size,  con- 
sistency, and  rapidity  of  growth  of  the  tumor,  whether  the 
tumor  is  freely  movable  or  fixed  to  the  surrounding  tissues, 
whether  it  is  painful,  whether  it  is  encapsulated,  whether  it 
has  given  ri.se  to  metastases,  and  whether  these  have  occurred 
thi-ough  the  lymphatics  or  through  the  blood-vessels,  whether 
tlie  neighboring  lymphatic  glands  are  involved,  and  the  pres- 
ence or  absence  of  cachexia. 

What  is  the  most  common  seat  of  rupture  of  the  quad- 
riceps extensor  femoris?  Give  the  symptoms  and  treat- 
ment. 

At  its  insertion  into  the  patella. 

Symptoms:  Sudden  pain  in  the  part,  inability  to  extend 
36 


562  SURGERY. 

the  leg,  and  the  appearance  of  ecchymosis  several  days  after 
the  injury.  A  swelling  may  be  felt  just  above  the  patella 
(extravasation)  or  a  gap  may  be  observed  (retraction  of 
muscle). 

Treatment :  The  treatment  usually  advised  is  to  place  the 
part  at  rest,  the  leg  being  extended  on  the  thigh,  and  the  thigh 
being  flexed  at  the  hip.  This  position  tends  to  bring  the 
torn  ends  together.  A  certain  amount  of  compression  is  made 
at  the  site  of  the  injury,  and  the  extremity  is  kept  in  the 
position  described  until  union  has  occurred.  If  perfect 
asepsis  can  be  obtained,  however,  primary  suture  of  the  mus- 
cle (if  healthy)  will  give  better  results. 

What  are  the  steps  in  the  ligation  of  arteries? 

The  preparation  of  the  region  in  which  the  vessel  is  situated 
for  an  aseptic  operation,  the  incision  dividing  the  skin  and 
superfical  fascia  (at  an  angle  of  about  five  degrees  to  the 
course  of  the  artery),  the  division  of  the  deep  fascia,  the 
recognition  of  muscular  or  bony  landmarks,  and  the  location 
of  the  vessel  by  its  pulsations,  the  opening  of  the  sheath,  the 
passage  of  the  aneurysm  needle,  the  tying  of  the  ligature,  and 
the  closure  of  the  wound. 

Give  the  treatment  for  talipes  calcaneus. 

Division  of  the  extensor  tendons.  If  the  tendo-Achillis  is 
attenuated,  a  portion  of  it  may  be  excised  and  the  ends  united 
by  suture.  In  other  eases  the  tendon  of  a  healthy  peroneus 
longus  may  be  grafted  into  the  tendo  Achillis,  or  the  tubercle 
of  the  OS  calcis,  into  which  the  tendo  Achillis  is  inserted,  may 
be  sawn  off  and  reattached  by  a  peg  to  the  bone  at  a  lower 
level  (Walsham).  In  the  paralytic  variety  some  form  of 
apparatus  must  always  be  worn. 

What  are  the  causes  and  treatment  of  paraphimosis? 

Causes:  Gonorrheal  balano-posthitis,  ulceration  from  chan- 
cre or  chancroid,  violent  coitus,  and  edema  following  upon 
the  retraction  of  a  tight  prepuce. 

Treatment:    The    glans   should   be    rendered   bloodless   by 


SUEGERY.  563 

digital  pressure  or  by  the  compression  of  a  finger  bandage 
and  well  anointed  with  sweet  oil.  The  index  and  middle 
fingers  of  each  hand  are  now  crossed  behind  the  glans  and  an 
attempt  made  to  force  the  glans  through  the  constricted  pre- 
putial orifice  by  pressing  upon  it  with  the  thumbs.  If  the 
edema  of  the  prepuce  is  very  marked,  it  may  be  punctured  in 
several  places  to  relieve  tension.  Should  this  measure  fail, 
the  preputial  orifice  (at  the  bottom  of  the  second  groove)  is 
to  be  divided  with  a  sharp-pointed,  curved  bistoury.  Lead 
water  and  laudanum  may  then  be  applied  to  reduce  the  in- 
riammatory  swelling. 

In  what  portion  of  the  base  of  the  skull  may  fractures 
lead  to  the  escape  of  cerebro=spinal  fluid? 

Cerebro-spinal  fluid  may  escape  through  the  nose  in  a  frac- 
ture of  the  anterior  fossa  involving  the  cribriform  plate  of 
the  ethmoid  (if  there  is  a  laceration  of  the  mucous  membrane 
below  the  fracture  and  of  the  dura  and  arachnoid  above  it) ; 
it  may  escape  through  the  ear  in  a  fracture  of  the  middle 
fossa  (if  the  fracture  passes  across  the  internal  auditory 
meatus,  if  the  tubular  prolongations  of  the  membranes  in  this 
meatus  are  torn,  if  there  is  a  communication  between  the 
internal  ear  and  the  tympanum,  and  if  the  membrana  tym- 
l)ani  is  lacerated). 

Give  the  symptoms  of  sacro-iliac  disease  and  mention 
the  affections  from  which  it  must  be  differentiated. 

Pain  and  a  sensation  of  weakness  in  the  lower  part  of  the 
back,  which  is  increased  by  standing,  sneezing,  or  any  move- 
ment which  suddenly  calls  the  abdominal  muscles  into  play 
and  drags  on  the  ilium.  The  unfortunate  individual  feels 
as  though  his  pelvis  were  coming  to  pieces.  The  pain  is  fre- 
•  luently  referred  to  the  gluteal  region  or  leg  (lumbo-sacral 
cord).  If  the  pelvis  is  not  supported,  movements  of  the  lower 
extremity  are  painful.  There  is  apparent  lengthening  upon 
the  affected  side,  owing  to  the  tilting  downwards  and  forwards 
of  the  innominate  bone.     Lateral   compression  of  the  pelvis 


564  SURGERY. 

causes  pain.  The  region  over  the  joint  is  often  swollen  and 
tender.  Abscesses  may  form,  and  these  may  point  over  the 
articulation,  upwards  into  the  lumbar  region,  forwards  into 
the  groin,  or  downwards  into  the  pelvis.  Sacro-iliac  disease 
must  be  differentiated  from  sciatica,  hip-joint  disease,  and 
lumbar  spondylitis. 

Give  the  differential  diagnosis  between  fracture  of  the 
neck  of  the  humerus  and  dislocation  of  the  shoulder  joint. 

Fracture.  Dislocation. 

Elbow  readily  approximated  to  side.       Elbow  cannot  be  approximated  to 

side  without  causing  great  pain. 

Elbow  can  be  made  to  touch  chest  Elbow  cannot  be  made  to  touch 
with  hand  of  affected  extremity  chest  with  hand  of  affected  ex- 

upon  the  sound  shoulder.  tremity  upon  the  sound  shoulder. 

Crepitus.  No  crepitus. 

Preternatural  mobility.  More  or  less  fixation. 

Shape  of  shoulder- J9int  unchanged.       Flattening    of    shoulder-joint,    the 

head  of  the  bone  being  felt  in 
an  abnormal  position. 

Deformity  recurs  after  reduction.  Deformity  does  not  recur  after  re- 
duction. 

Shortening    of    the    arm.  Elongation   may   be   present    (sub- 

glenoid), or  the  arm  may  be  of 
same  length  as  that  of  opposite 
side. 

What  are  the  indications  for  thyroidectomy? 

Fibro-adenomatous  and  cystic  goitres,  parenchymatous 
goitres  which  increase  in  size  in  spite  of  palliative  treatment, 
and  carcinoma  and  sarcoma  of  the  thyroid  gland. 

Describe  active  congestion,  passive  congestion.  State 
their  points  of  difference. 

Active  congestion  is  an  increase  in  the  amount  of  blood  in 
the  more  or  less  dilated  arteries  of  a  part,  with  an  increase  in 
the  velocity  of  the  blood  stream. 

Passive  congestion  is  an  increase  in  the  amount  of  blood  in 
the  more  or  less  dilated  veins  and  capillaries  of  a  part,  with  a 
diminished  velocity  of  the  blood  stream. 


SURGERY.  565 

In  active  congestion  the  part  is  reddened,  not  perceptibly 
enlarged,  and  the  velocity  of  the  blood  current,  the  tempera- 
ture and  the  functional  activity  of  the  part  are  increased. 

In  passive  congestion  the  part  is  bluish,  greatly  swollen, 
and  the  velocity  of  the  blood  current,  the  temperature  and 
the  functional  activity  of  the  part  are  diminished. 

What  is  the  usual  site  of  a  vulvovaginal  abscess?  Give 
the  symptoms  and  treatment. 

In  the  glands  of  Bartholin  at  either  side  of  the  entrance  of 
the  vagina. 

Symptoms :  Heat,  redness,  and  tenderness,  together  with  a 
peculiar  pyriform  swelling.  In  the  early  stages  this  swelling 
is  best  detected  by  introducing  the  finger  in  the  vagina  and 
pressing  outward  against  the  pubic  ramus. 

Treatment :  Incision  and  drainage.  The  wound  should  be 
irrigated,  packed  with  iodoform  gauze,  and  made  to  heal  up 
from  the  bottom.  The  principles  of  antisepsis  obtain  here  as 
elsewhere. 

How  would  you  operate  for  the  radical  cure  of  complete 
fistula  in  ano? 

The  bowels  should  be  completely  evacuated  by  a  suitable 
purgative,  and  also  by  an  enema,  about  an  hour  before  the 
operation.  The  patient  is  etherized,  placed  in  the  lithotomy 
position,  and  the  perineal  and  anal  regions  shaved  and  prop- 
erly cleansed.  The  e.xternal  sphincter  is  forcibly  stretched 
by  the  thumbs  in  the  rectum,  and  a  grooved  director  is  then 
passed  into  the  external  orifice  of  the  fistula,  through  the 
fistulous  tract,  and  brought  out  through  the  internal  orifice. 
A  curved  bistoury  is  now  introduced  along  the  grooved 
director,  and  all  the  overlying  tissues  are  divided.  .Ml 
pockets  and  tributary  branches  of  the  fistula  must  be  opened 
up  and  curetted.  All  undermined  tissue  and  unhealthy  tags 
of  skin  should  be  removed.  Hemorrhage  should  be  checked, 
the  cavity  carefully  packed  with  iodoform  gauze,  and  com- 
pression made  over  the  anal  region  by  a  thick  pad  of  sterile 
gauze  and  a  T-binder. 


566  8UEGEBY. 

What  affections  occur  on  the  female  external  genitalia? 

Vulvitis,  vulvovaginal  abscess,  vulvovaginal  cyst,  hema- 
toma of  vulva,  pruritus  vulvae,  hypertrophy  of  the  clitoris  or 
of  the  nymphae,  urethral  caruncle,  noma  pudendi,  chancre, 
chancroid,  syphilitic  ulcerations,  venereal  warts,  papilloma, 
myxoma,  and  epithelioma.  A  labial  hernia  or  a  hydrocele  of 
the  round  ligament  may  make  its  appearance  in  this  situa- 
tion. 

What  is  the  cause  of  the  impulse  felt  in  a  scrotal  hernia 
on  coughing?  When  is  this  impulse  absent  in  such  a  her= 
nia,  and  in  what  other  condition  resembling  hernia  may  it 
be  present? 

In  a  scrotal  hernia  a  portion  of  the  abdominal  cavity  is,  so 
to  speak,  within  the  scrotum,  and  any  increase  in  the  intra- 
abdominal pressure  will,  of  course,  be  transmitted  to  the 
hernial  sac. 

This  impulse  is  absent  when  stran^lation  is  present. 

An  impulse  on  coughing  may  be  present  in  a  congenital 
hydrocele. 

Differentiate  between  true  and  false  sacculated  aneu= 
rysm. 

The  sac  of  a  true  sacculated  aneurysm  contains  all  of  the 
coats  of  the  blood-vessels.  In  a  false  sacculated  aneurysm 
some  of  the  coats  of  the  blood-vessel  are  absent. 

Describe  the  signs  of  each  variety  of  fistula  in  ano. 

Complete  fistula:  There  is  an  external  opening  in  the  skin 
and  an  internal  opening  in  the  bowel. 

In-complete  external  fistula:  There  is  an  external  opening, 
but  no  internal  opening. 

lur-complete  internal  fistula :  There  is  an  internal  opening, 
but  no  external  opening.  The  internal  opening  may  be  dis- 
covered by  direct  inspection  through  a  speculum  and  some- 
times by  palpation.  This  fistula  is  often  associated  with 
undermining  of  the  mucous  membrane  or  with  stenosis  of  the 
bowel.  Signs  of  inflammation  may  be  present  and  pus  may 
be  discharged  from  the  rectum. 


SURGERY.  567 

Describe  the  anatomic  varieties  of  abdominal  hernia. 

Oblique,  or  external  inguinal :  The  hernia  in  all  cases  enters 
the  inguinal  canal  through  the  internal  abdominal  ring,  ex- 
ternal to  the  deep  epigastric  artery.  This  variety  is  called 
complete  if  it  escapes  through  the  external  abdominal  ring 
(scrotal  hernia  in  the  male,  labial  in  the  female)  ;  it  is  called 
incomplete  (bubonocele)  if  it  remains  in  the  inguinal  canal. 

Direct,  or  internal  inguinal :  The  hernia  gains  entrance  to 
the  inguinal  canal  by  passing  through  Hesselbach's  triangle 
(bounded  by  edge  of  rectus,  deep  epigastric  artery,  and  Pou- 
part's  ligament).  It  does  not  pass  through  the  internal 
abdominal  ring,  and  the  neck  of  the  hernia  is  internal  to  the 
deep  epigastric  artery. 

Femoral :  The  hernia  passes  out  of  the  abdominal  cavity 
through  the  femoral  canal  and  makes  its  appearance  iipon  the 
thigh. 

Umbilical :  The  hernia  passes  through  the  umbilical  ring. 

Obturator:  The  hernia  passes  through  the  obturator  canal 
and  may  make  its  appearance  upon  the  thigh. 

Sciatic :  The  hernia  passes  out  of  the  pelvis  through  one  of 
the  sacro-sciatic  foramina  (usually  through  the  greater)  and 
makes  its  appearance  at  the  lower  border  of  the  gluteus  maxi- 
mus.  The  neck  of  the  hernia  is  above  the  great  sacro-sciatic 
ligament. 

Perineal :  All  hernias  which  protrude  through  the  muscular 
floor  of  the  pelvis  toward  the  perineum  are  designated  as 
perineal  hernias.  The  neck  of  the  hernia  is  below  the  great 
sacro-sciatic  ligament.  They  receive  special  names  according 
as  to  whether  the  skin,  the  vagina,  or  the  rectum  is  pushed 
in  advance  of  the  hernial  protrusion. 

Inguino-perineal  (Coley)  :  A  hernia  avSsociated  with  mal- 
descent  of  the  testis.  In  these  cases  the  testicle  is  in  the 
perineum  and  the  hernia  follows  the  testicle. 

Diaphragmatic :  The  hernia  protrudes  through  the  dia- 
phragm. Many  of  these  cases  are  not  true  hernias,  as  they 
have  no  sac  of  peritoneum. 


568  SURGERY. 

Ventral :  The  hernia  appears  at  any  portion  of  the  anterior- 
abdominal  wall  except  the  umbilicus.  They  are  subdivided 
into  epigastric  hernia  (in  the  median  line  above  the  navel) ^ 
hernia  of  the  linea  alba  (below  the  navel),  and  lateral  ventral 
hernia. 

Lumbar :  A  hernia  making  its  appearance  in  the  lumbar 
region.  It  is  commonly  taught  that  it  passes  through  Petit 's 
triangle,  but  no  such  instance  has  ever  been  proved  by  dis- 
section (Sultan).  In  some  instances  it  passes  through. 
Braun's  space. 

Internal  hernias :  1.  Hernia  through  the  foramen  of  Wins- 
low.  2.  Hernia  through  the  duodeno- jejunal  recess  (retro- 
peritoneal) .  3.  Hernia  through  the  retro-cecal  and  ileo-cecal 
recesses  (retro-peritoneal).  4.  Hernia  through  the  inter- 
sigmoid  recess  (retro-peritoneal).  5.  Retro- vesical  hernia. 
The  lateral  vesico-umbilical  fold  is  so  markedly  developed 
that  a  peritoneal  pocket  is  produced  at  one  side. 

Describe  the  symptoms  and  give  the  treatment  of  hem- 
orrhage from  the  middle  meningeal  artery. 

Symptoms:  The  first  symptoms  are  those  of  concussion. 
These  are  followed  by  a  temporary  return  of  consciousness 
(very  important)  and  the  gradual  onset  of  coma  within  24 
hours,  usually  without  any  rise  in  the  temperature.  Since 
the  blood  clot  presses  upon  the  motor  area,  localized  twitch- 
ings  or  paralyses  may  be  present.  The  paralysis  is  apt  to  be 
progressive,  commencing  in  the  face  and  then  extending  to 
the  arm  and  leg.  If  the  clot  gravitates  toward  the  base  the 
pupil  of  the  same  side  will  be  dilated  and  immobile ;  if  on  the 
left  side  aphasia  will  be  present,  the  pulse  will  be  frequent, 
the  respiration  slow  and  stertorous,  and  the  temperature  will 
rise  to  101°  to  103°  (or  even  higher)  upon  the  side  opposite 
the  clot. 

Treatment :  The  anterior  branch  of  the  middle  meningeal 
is  the  one  commonly  involved,  but  the  posterior  may  also  be 
the  source  of  the  bleeding.  After  all  aseptic  precautions 
have  been  carried  out.  a  semicircular  flap  is  turned  down  and 


SURGERY.  569 

the  skull  trephined.  The  pin  of  the  trephine  is  placed  upon 
a  point  one  and  one-fourth  inches  behind  the  external  angular 
process  at  the  level  of  the  upper  border  of  the  orbit  (anterior 
branch).  If  the  clot  is  not  found  the  trephine  should  be 
immediately  reapplied  just  below  the  parietal  eminence  at 
the  same  level  as  the  first  opening  (posterior  branch).  The 
clot  should  now  be  removed,  the  trephine  opening  being  en- 
larged with  rongeur  forceps  if  necessary,  and  the  cavity 
thoroughly  irrigated  with  sterile  water.  If  the  artery  is  still 
bleeding  it  should  be  tied  by  passing  a  cat-gut  ligature  through 
the  dura  and  about  the  artery  by  means  of  a  Hagedorn  needle. 
Drainage  should  be  provided  for  and  the  wound  closed  in  the 
ordinary  manner.  If  there  is  evidence  that  the  clot  is  gravi- 
tating toward  the  base,  the  first  trephine  opening  should  be 
made  at  a  point  one-half  inch  lower  than  that  above  given. 

Give  symptoms  and  treatment  of  fracture  of  the  nasal 
bones. 

Symptoms:  Crepitus,  deformity  (depression  or  lateral  dis- 
placement) ,  preternatural  mobility,  swelling,  and  ecehymosis. 
Severe  epistaxis,  surgical  emphysema,  and  cerebral  symptoms 
are  occa.sioually  encountered. 

Treatment :  Reduction  at  the  earliest  possible  moment  in 
order  to  avoid  the  peristence  of  the  deformity.  It  is  best 
to  give  an  anesthetic,  as  these  parts  are  exceedingly  sensi- 
tive, and  the  reduction  should  be  accurate  and  deliberate. 
The  fragment  is  best  returned  to  its  proper  position  by  a 
padded  dressing  forceps  carried  well  up  into  the  nose  and 
a.ssisted  by  external  manipulation.  Should  there  be  any 
tendency  toward  a  recurrence  of  the  displacement  the  nasal 
chamber  should  be  carefully  packed  with  sterile  gauze  and 
the  packing  renewed  every  24  hours. 

Describe  the  steps  in  the  operation  of  stretching  the 
facial  nerve. 

After  the  aseptic  precautions  have  been  observed,  an  incis- 
ion  is  made  commencing  bfliind   the  pinna  opposite  the  ex- 


570  SURGERY. 

ternal  auditory  meatus  and  extending  downward  and  forward 
behind  the  lobule  of  the  ear  to  the  angle  of  the  jaw.  This 
incision  divides  the  skin,  superficial  fascia,  superficial  layer 
of  the  deep  fascia,  and  branches  of  the  auricularis  magnus 
nerve.  The  fiaps  are  now  dissected  from  the  parotid  gland, 
sterno-mastoid  muscle,  and  mastoid  process,  care  being  taken 
to  avoid  the  posterior  auricular  nerve,  vein,  and  artery.  The 
internal  jugular  vein  is  close  to  the  posterior  margin  of  the 
wound.  After  the  parotid  gland  has  been  separated  from 
the  mastoid  process  the  trunk  of  the  nerve  is  found  lying  on 
the  styloid  process  just  above  the  posterior  belly  of  the  digas- 
tric muscle.  The  nerve  is  stretched  by  lifting  it  up  with  a 
blunt  hook.  The  external  incision  is  sutured  and  an  anti- 
septic dressing  applied. 

How  would  you  expose  the  brachial  artery  for  ligation 
in  the  middle  of  the  arm? 

After  all  aseptic  precautions  have  been  observed,  an  incis- 
ion is  made  along  the  inner  edge  of  the  biceps  muscle.  The 
line  of  the  artery  is  from  a  point  just  to  the  inner  side  of  the 
center  of  the  clavicle  to  midway  between  the  two  condyles. 
The  incision  divides  the  skin,  superficial  fascia,  twigs  of  the 
internal  cutaneous  nerves,  and  small  branches  of  the  superior 
profunda  and  anterior  circumflex  arteries.  The  deep  fascia 
IS  now  divided  and  the  inner  edge  of  the  biceps  recognized. 
The  arm  should  be  held  at  right  angles  to  the  body  and  not 
allowed  to  rest  upon  any  support,  since  the  triceps  muscle 
would  displace  the  biceps  and  our  muscular  guide  would  be 
lost.  The  biceps  is  now  displaced  outwards  and  the  pulsa- 
tions of  the  artery  sought  for.  The  median  nerve  generally 
lies  over  the  artery  in  this  position  of  the  arm.  It  should  be 
drawn  inward  and  the  sheath  of  the  vessel  opened. 

Give  the  treatment  of  foreign  bodies  in  the  trachea. 

The  performance  of  a  low  tracheotomy,  a  sufficiently  exten- 
sive opening  being  made  in  the  trachea.  If  the  foreign  body 
cannot  be  removed  at  the  time  of  the  operation,  by  means  of 
delicate  forceps,  coin-catcher,  wire  loop,  or  hooked  probe,  the 


SUBGEBY.  571 

edges  of  the  tracheal  wound  should  be  sutured  to  the  cuta- 
neous incision,  and  the  foreign  body,  if  movable,  will  usually 
be  spontaneously  expelled.  If  the  foreign  body  is  not  ex- 
pelled within  a  day  or  two,  the  trachea  and  bronchi  should 
be  examined  with  a  long  probe.  This  excites  violent  cough- 
ing, which  may  dislodge  the  foreign  body.  The  patient  may 
be  also  inverted  and  simultaneously  stn^ick  upon  the  back  at 
the  level  of  the  tracheal  bifurcation  (fourth  dorsal  vertebra). 

Describe  a  method  of  differentiating  between  (a)  the 
urethra,  (b)  the  bladder,  and  (c)  the  kidneys  as  the 
sources  of  pus  in  the  urine. 

Urethra :  It  is  usually  stated  that  if  the  urine  is  passed  into 
two  beakers,  the  first  quantity  wall  be  turbid  and  the  second 
one  clear.  If  the  pus  originates  in  the  posterior  urethra, 
however,  it  regurgitates  into  the  bladder  and  both  specimens 
will  be  turbid.  (Finger).  The  urine  will  usually  be  acid, 
the  pus  will  be  in  small  quantities,  and  there  will  be  signs  of 
the  local  inliammation. 

Bladder :  The  freshly  drawn  urine  will  be  alkaline,  and  may 
contain  crystals  of  triple  phosphate.  The  urine  is  increased 
in  amount,  and  the  last  portions  passed  contain  ropy,  thick 
mucus.  It  may  be  possible  to  identify  bladder  cells  in  the 
sediment,  and  the  pus  corpuscles  are  said  to  be  better  formed 
than  when  they  originate  in  the  kidney. 

Kidney:  In  pyonephrosis  the  discharge  of  pus  may  be 
intermittent,  clear  specimens  being  obtained  for  days  or  even 
weeks.  In  calculous  and  tubercular  pyelitis  the  pyuria  is 
usually  continuous.  The  pus  is  more  intimately  mixed  with 
the  urine  than  when  it  originates  in  the  bladder  or  urethra, 
and  the  urine  is  acid  in  reaction. 

In  all  three  instances  the  history  of  the  case  will  be  of 
value.  The  most  accurate  differentiation  can  be  made  by 
cystoscopy. 

Describe  in  detail  the  condition  known  as  talipes  equino* 
varus. 

In  the  affection  known  as  talipes  equino-varus  the  heel  is 


572  SURGERY. 

drawn  up  and  the  anterior  half  of  the  foot  is  adducted  and 
drawn  inwards.  The  inner  border  of  the  sole  is  concave,  and 
traversed  by  a  sulcus  corresponding  to  the  positron  of  the 
mid-tarsal  joint;  the  outer  border  is  convex,  and  this  con- 
vexity is  usually  covered  by  a  bursa.  The  sole  of  the  foot  is 
arched  from  secondary  contraction  of  the  plantar  fascia  and 
some  of  the  plantar  muscles  (particularly  the  abductor  hal- 
lucis) ,  and  its  center  may  be  marked  by  a  longitudinal  crease 
due  to  a  folding  over  of  the  outer  metatarsal  bones.  The 
individual  walks  upon  the  outer  border  of  the  foot,  and,  in 
neglected  cases,  even  upon  the  dorsal  aspect  of  the  cuboid 
bone. 

In  acquired  cases  the  extensor  and  peroneal  muscles  are 
paralyzed,  and  the  tibialis  anticus,  tibialis  posticus,  flexor 
longus  digitorum,  and  the  tendo-Achillis  are  secondarily 
shortened. 

The  astragalus  is  displaced  forwards  and  outwards,  and  is 
the  most  deformed  of  all  the  tarsal  bones.  The  neck  of  the 
bone  is  elongated,  and  the  angle  between  the  neck  and  the 
body,  instead  of  being  35  degrees  (child)  or  10  degrees 
(adult),  is  increased  to  50  degrees  or  even  more.  The  sca- 
phoid is  pushed  to  the  inner  side  of  the  astragalus,  the  tuber- 
osity approaching  or  even  touching  the  internal  malleolus. 
The  ligaments  on  the  inner  side  of  the  foot  are  contracted 
(anterior  portion  of  deltoid),  inferior  calcaneo-scaphoid,  long 
and  short  plantar  ligaments) . 

What  means  has  the  surgeon  at  his  command  for  the 
separation  of  tissues? 

Knife  (scalpel,  bistoury,  tenotome),  scissors,  thermo-cau- 
tery,  ecraseur,  snare,  elastic  constriction,  saw,  trephine, 
chisel,  osteotome,  and  the  osteoclast. 

Describe  talipes  equinus  and  give  its  treatment. 

In  the  alfection  known  as  talipes  equinus  the  heel  is  drawn 
up  so  that  the  patient  walks  upon  the  metatarso-phalangeal 
joints  and  the  toes.     The  degree  of  deformity  ranges  from. 


SURGERY.  573 

those  cases  m  which  there  is  simply  a  slight  elevation  of  the 
heel  to  those  in  which  the  foot  is  almost  vertical,  and  the 
plantar  muscles  and  fascia  so  contracted  that  the  patient 
walks  upon  the  heads  of  the  metatarsal  bones,  the  toes  being 
in  a  position  of  hyperextension  (or  even  of  hyperflexion). 

Treatment:  The  milder  cases  may  be  treated  by  means  of 
Sayre's  apparatus,  but  subcutaneous  division  of  the  tendo- 
Achillis  is  usually  required.  The  foot  is  subsequently  placed 
in  its  normal  position  and  put  in  plaster  of  Paris.  The  foot 
is  kept  in  plaster  for  three  months,  and  a  mechanical  support 
(rendering  extension  beyond  a  right  angle  impossible)  should 
be  worn  for  a  year.  In  severe  cases  it  may  be  necessary  to 
divide  the  plantar  fascia  and  elongate  the  tendo-Achillis  by 
splicing.  In  the  most  obstinate  cases  some  surgeons  excise 
the  astragalus. 

What  are  the  symptoms  of  a  foreign  body  In  the  stom= 
ach?     Give  the  treatment. 

The  symptoms  of  a  foreign  body  in  the  stomach  are  fre- 
quently most  obscure.  There  may  be  a  sensation  of  weight 
and  distress,  and  if  the  object  is  rough  and  irritating  there 
may  be  local  tenderness  and  vomiting  of  blood-tinged  fluid. 
Tlie  X-ray  will  usually  furnish  valuable  aid. 

Treatment:  If  the  foreign  body  is  small,  non-irritating,  and 
capable  of  being  passed  per  rectum,  the  patient  should  be 
made  to  eat  large  quantities  of  foods  leaving  a  considerable 
residue.  If  the  foreign  body  will  not  pass  the  pylorus  it 
should  be  removed  by  gastrotoiny. 

What  are  the  causes  of  acute  prostatitis?  Describe  a 
typical  case  of  acute  prostatitis  and  give  the  treatment. 

Causes:  Urethritis  (usually  gonorrheal),  traumatism,  strict- 
ure, retention  of  decomposing  urine,  prostatic  calculi,  and 
cystitis. 

Symptoms:  Deep-seated  pain,  accompanied  by  a  sensation 
of  heat  and  weight  in  tlie  perineum.  The  desire  to  pass  water 
is  frequent  and  micturition  is  painful,  particularly  at  the 
conclusion    of   tlie    act.     Defecation    is    painful,    and   digital 


574  SURGERY. 

examination  per  rectum  reveals  a  hot  and  exquisitely  tender 
swelling  of  the  prostate  gland.  The  perineum  is  also  hot  and 
tender.  The  patient  cannot  sit  comfortably,  but  will  support 
his  weight  upon  one  buttock  to  avoid  any  pressure  upon  his 
perineum.  If  suppuration  occurs,  as  is  usually  the  ease,  the 
pain  becomes  more  marked  and  of  a  throbbing  character,  the 
perineum  becomes  red  and  edematous,  retention  of  urine  may 
occur,  and  the  passage  of  a  catheter  causes  excruciating  pain. 
Fever  is  present,  and  there  may  be  a  marked  chill.  The 
abscess  may  discharge  through  the  urethra,  rectum,  perineum, 
or  above  Poupart's  ligament. 

Treatment :  Absolute  rest  in  bed,  and  a  bland,  non-irritating 
diet.  The  bowels  should  be  kept  loose  to  avoid  the  pressure 
of  hardened  feces  upon  the  inflamed  organ.  Hot  hip  baths 
sometimes  cause  a  marked  diminution  of  the  pain.  If  the 
case  is  seen  early,  leeches  followed  by  hot  fomentations  should 
be  applied  to  the  perineum.  If  the  pain  is  intense,  supposi- 
tories of  morphine  and  belladonna  should  be  given.  If  reten- 
tion is  present  the  urine  should  be  drawn  off  with  a  small 
rubber  catheter.  If  suppuration  has  occurred  the  passage  of 
the  catheter  will  occa.sionally  rupture  the  abscess,  which  may 
then  evacuate  itself  through  the  urethra.  If  this  does  not 
occur,  and  there  are  evidences  of  deep-seated  suppuration, 
or  if  the  pus  does  not  discharge  freely,  the  patient  should  be 
etherized  and  placed  in  the  lithotomy  position.  The  finger 
is  now  introduced  into  the  rectum  and  an  incision  made  in 
the  median  line  of  the  perineum  down  to  the  seat  of  pus  for- 
mation. The  abscess  cavity  is  then  evacuated,  irrigated,  and 
a  drainage  tube  introduced. 

Give  the  course,  symptoms,  and  treatment  of  varicocele. 

Course:  The  affection  appears  in  early  adult  life  (rarely 
after  35),  and  is  practically  always  upon  the  left  side,  vari- 
cocele of  the  right  side  alone  being  almost  unheard  of.  In 
many  cases  it  persists  throughout  life  without  any  injury  to 
the  individual,  while  in  some  cases  it  may  lead  to  atrophy  of 
the  testicle. 

Symptoms:  A  swelling  situated  along  the  spermatic  cord 


SURGERY.  515 

and  feeling  like  a  bunch  of  earth-worms.  The  swelling  is 
compressible,  gives  an  impulse  upon  coughing,  disappears 
when  the  patient  lies  down,  and  reappears  when  he  stands  up, 
even  though  firm  pressure  is  made  over  the  site  of  the  external 
ring.  In  most  cases  the  scrotum  is  relaxed  and  flabby,  and 
there  may  be  a  sensation  of  dragging  weight,  or  even  of  actual 
pain.  The  testicle  upon  the  affected  side  may  be  smaller  or 
flabby,  but  it  is  nearly  always  perfectly  healthy.  Many  indi- 
viduals with  this  affection  woriy  themselves  into  a  condition 
of  mental  disquietude  out  of  all  proportion  to  the  local  dis- 
ease. 

Treatment.     Palliative :  A  well-fitting  suspensory  bandage. 

Operative :  Operative  treatment  is  to  be  adopted  if  the 
patient  desires  to  enter  the  army  or  navy,  if  the  affection 
causes  physical  discomfort  despite  the  wearing  of  a  suspen- 
sory, and  if  the  mental  condition  of  the  patient  cannot  be 
relieved  until  the  varicocele  is  removed.  The  operation  for 
the  cure  of  varicocele  consists  of  the  excision  of  a  section  of 
the  dilated  veins.  The  incision  is  to  be  made  in  the  groin, 
and  not  in  the  scrotum,  as  was  formerly  practiced.  About 
two  inches  of  the  cord  is  drawn  up  through  the  incision,  the 
vas  deferens  (feels  like  a  "whip-cord")  and  its  accompany- 
ing vessels  are  carefully  isolated  and  not  included  in  the 
double  ligature  (chromicized  cat-gut).  The  ligatures  are 
placed  at  a  distance  of  from  one  to  two  inches  from  each 
other  and  the  intervening  bundle  of  veins  is  removed.  One 
end  of  each  ligature  is  cut  short,  and  the  other  ends  are  tied 
so  that  the  cord  is  shortened  and  the  testicle  elevated.  To 
insure  accurate  apposition  of  the  two  stumps  it  is  well  to 
insert  one  or  two  sutures  of  fine  cat-gut.  All  hemorrhage 
must  be  thoroughly  arrested  to  insure  the  best  results.  The 
testicle  is  now  drawn  down  into  the  scrotum  and  the  cuta- 
neous incision  sutured  in  the  customary  manner. 

Describe  McBurney's  "  grid=iron  "  incision  for  appen- 
dicitis. What  is  the  advantage  of  this  incision  and  what 
is  the  disadvantage? 

After  the  skin   has  been  carefully  disinfected,  an  oblique 


576  SURGERY. 

incision  about  three  inches  in  length  is  made,  commencing 
one  inch  above  McBurney's  line  and  crossing  this  line  about 
an  inch  and  a  half  internal  to  the  anterior-superior  spine. 
The  position  of  the  incision  will  naturally  vary  somewhat 
according  to  the  location  of  the  swelling,  but  it  should  always 
be  made  in  the  direction  of  the  fibres  of  the  external  oblique 
muscle.  The  aponeurosis  of  the  external  oblique  and  a  small 
portion  of  the  muscle  itself  are  now  divided  in  the  direction 
of  the  external  incision.  The  fibres  of  the  external  oblique 
muscle  should  be  separated  (not  incised),  great  care  being 
taken  that  none  of  the  fibres  are  divided  transversely.  Re- 
tractors are  now  placed  in  the  wound  and  the  internal  oblique 
and  the  transversalis  muscles  are  similarly  split  in  the  direc- 
tion of  their  fibres.  The  transversalis  fascia  and  peritoneum 
are  then  divided  in  the  usual  manner. 

The  advantage  of  the  incision  is  that  the  abdominal  wall  is 
not  weakened  as  much  as  if  the  muscular  fibres  were  cut 
•across,  and  therefore  there  is  consequently  less  tendency  to 
subsequent  ventral  hernia. 

The  disadvantage  of  the  incision  is  that  the  amount  of 
room  to  work  in  is  somewhat  lessened,  and  the  performance 
of  the  operation  consequently  rendered  more  difficult. 

What  is  the  difference  between  congestion  and  inflam^ 
mation? 

Arterial  congestion  is  an  excess  of  blood  in  the  more  or  less 
■dilated  arteries  of  a  part,  the  velocity  of  the  blood-current 
being  increased.  The  part  is  reddened,  the  temperature  is 
increased,  swelling  is  scarcely  appreciable,  pain  is  not  present, 
•except  that  the  patient  may  complain  of  a  throbbing  sensa- 
tion, and  the  function  and  nutrition  of  the  part  are  increased. 
If  the  congestion  continues  the  part  becomes  either  hyper- 
trophied  or  inflamed. 

"Inflammation  is  the  succession  of  changes  which  occur  in 
a  living  tissue  when  it  is  injured,  provided  that  the  injury  is 
not  of  such  a  degree  as  to  at  once  destroy  its  structure  and 
■vitality."     (Burden  Sanderson).     The  part  is  reddened,  the 


SURGE  HY.  bll 

temperature  is  increased,  swelling  may  be  considerable,  and 
pain  is  present  dependent  upon  the  character  of  the  tissue 
involved  and  the  severity  of  the  inflammation.  The  function 
of  the  part  is  diminished  and  fever  is  usually  present. 

How  would  you  diagnose  and  treat  a  case  of  fracture  of 
both  bones  of  the  forearm  occurring  at  the  middle  third? 

The  diagnosis  is  usually  apparent  at  a  glance.  There  will 
he  angular  deformity,  as  a  rule,  crepitus,  a  new  point  of 
motion  (preternatural  mobility),  pain,  and  subsequently 
swelling  and  ecchymosis.  The  power  of  supination  and  pro- 
nation is  entirely  lost.  In  those  cases  in  which  the  diagnosis 
might  be  doubtful  the  X-rays  will  reveal  the  nature  of  the 
lesion. 

Treatment:  Reduction  by  extension  and  counter-extension 
combined  with  manipulation  at  the  site  of  the  fracture. 
After  the  deformity  has  been  reduced  the  forearm  should  be 
kept  flexed  at  a  right  angle  to  the  arm  and  in  a  position 
midway  between  pronation  and  supination  (thumb  up!) 
Two  splints  should  be  applied,  a  palmar  extending  from  the 
bend  of  the  elbow  to  below  the  wrist.  The  splints  should  be 
flrmly  and  evenly  padded,  and  must  be  broad  enough  to  pre- 
vent circular  eon.striction  of  the  forearm.  A  primary  roller 
should  never  be  applied,  and  an  interosseous  pad  is  not  to  be 
employed.     Union  is  usually  complete  in  four  or  five  weeks. 

Define  amputation  in  the  continuity  and  amputation  in 
the  contiguity  of  a  limb. 

By  amputation  in  the  continuity  of  a  limb  is  meant  an 
amputation  through  the  bone  or  bones  of  the  extremity. 

By  an  amputation  in  the  contiguity  of  a  limb  is  meant  an 
amputation  through  any  of  the  joints  of  the  extremity. 

Define  the  following  terms:  (a)  Bursitis;  (b)  bunion; 
(c)  paronychia.     Give  the  treatment  for  each  disease. 

By  bursitis  is  meant  the  inflammation  of  a  bursa. 
By  a  bunion  is  meant  an  inflammation  of  one  of  the  bursae 
37 


578  SURGERY. 

about  the  foot,  usually  over  the  metatarso-phalangeal  joint 
of  the  great  toe. 

By  paronychia  or  felon  is  meant  an  inflammation  of  a  fin- 
ger. It  may  be  subcuticular,  subcutaneous,  thecal  (suppur-^ 
ative  teno-synovitis),  or  subperiosteal  (bone  felon). 

Simple  acute  bursitis  is  treated  by  keeping  the  part  at  rest 
and  the  application  of  fomentations.  If  the  effusion  per- 
sists it  may  be  aspirated  or  the  entire  cavity  may  be  excised. 
Suppurative  bursitis  should  be  treated  by  early  and  free 
incision  and  the  subsequent  maintenance  of  effective  drain- 
age. Chronic  bursitis  may  be  met  by  rest  and  counter-irri- 
tation ;  if  these  measures  fail  the  bursa  should  be  dissected 
out.  Special  care  must  be  exercised  in  dealing  with  bursas 
which  communicate  with  a  joint.  In  tuberculous  bursitis- 
the  part  should  be  freely  incised,  the  tubercular  tissue 
scraped  away,  and  the  cavity  packed  with  iodoform  gauze. 

The  treatment  of  bunion  is  that  of  acute  or  of  suppurative 
bursitis.  If  the  bone  is  diseased  it  must  be  removed,  and  any 
malposition  of  the  toe  corrected  during  the  period  of  conva- 
lescence. In  some  cases  the  underlying  joint  must  be  re- 
sected. 

All  varieties  of  paronychia  are  best  treated  by  a  free  and 
early  incision  extending  well  into  the  inflamed  area.  In  the 
subcuticular  and  subcutaneous  varieties  care  must  be  taken 
not  to  incise  the  sheaths  of  the  tendons  and  thus  give  rise  ta 
additional  infection.  In  the  subperiosteal  whitlow,  the  inci- 
sion should  go  down  to  the  bone,  and  cannot  be  made  too  early. 

Describe  the  various  steps  in  the  operation  of  inguinal 
colostomy. 

After  all  aseptic  precautions  have  been  observed,  an  inci- 
sion about  two  inches  in  length  is  to  be  made,  one  and  one- 
half  inches  above  and  parallel  with  the  outer  portion  of 
Poupart's  ligament.  This  incision  should  be  carried  down 
to  the  peritoneum.  All  hemorrhage  having  been  checked, 
the  parietal  peritoneum  is  to  be  incised  for  about  two-thirds 
the  length  of  the  external  wound  and  accurately  stitched  to 


SURGERY.  579 

the  skin.  While  this  step  of  the  operation  is  being  performed 
the  intestines  should  be  held  out  of  the  way  by  a  sterile  gauze 
pad.  After  the  colon  has  been  found  it  should  be  drawn  out 
of  the  wound,  pulling  from  above  downward,  and  returning 
the  protruding  bowel  through  the  lower  angle  as  it  is  drawn 
out  from  the  upper  one.  As  soon  as  the  colon  is  almost  taut, 
an  opening  is  made  in  the  meso-sigmoid  (or  descending  meso- 
colon, as  the  case  may  be)  and  a  glass  rod  passed  through  it 
so  as  to  bring  a  coil  of  intestine  out  of  the  wound,  the  ends  of 
the  rod  resting  upon  the  skin.  The  two  limbs  of  the  intes- 
tinal coil  are  fixed  by  suturing  them  together  beneath  the 
glass  rod.  An  aseptic  dressing  is  now  applied.  Adhesions 
will  be  sufficiently  firm  by  the  third  or  fifth  day,  when  the 
intestine  may  be  opened  by  a  transverse  incision.  This  latter 
step  may  be  performed  without  an  anesthetic.  A  few  days 
later  all  of  the  bowel  projecting  above  the  skin  may  be  cut 
away  and  the  bleeding  carefully  checked.  Should  it  be  neces- 
sary to  open  the  bowel  immediately,  the  intestine  should  be 
accurately  sutured  to  the  lips  of  the  cutaneous  incision  and 
a  Paul's  tube  tied  in  place. 

Describe  an  operation  for  wry=neck. 

Open  myotomy  of  the  sterno-cleido-mastoid  muscle.  All 
aseptic  details  having  been  observed,  the  skin  is  freely  incised 
about  a  half  inch  above  the  clavicle,  and  the  sterno-cleido- 
mastoid  muscle  is  freely  divided  at  the  level  of  the  cutaneous 
incision,  the  external  wound  is  closed,  and  an  aseptic  dressing 
is  applied.  The  faulty  position  of  the  head  is  then  over- 
corrected  and  fixed  in  its  new  position  by  a  plaster  of  Paris 
bandage  or  other  suitable  contrivance. 

What  are  the  causes  of  dysphagia? 

1.  Pharyngeal:  Acute  or  chronic  inflammation,  tubercu- 
losis, syphilis,  malignant  growths,  stricture,  paralysis,  naso- 
pharyngeal polypi,  impaction  of  foreign  bodies,  and  retro- 
pharyngeal abscess  or  tumor. 

2.  Laryngeal :  Acute  or  chronic  inflammation,  tuberculosis, 
syphilis,  or  malignant  growths. 


580  SURGERY. 

3.  Esophageal :  Acute  or  chronic  inflammation,  impaction 
of  foreign  bodies,  the  presence  of  diverticula,  esophagospasm, 
and  simple  or  malignant  stricture. 

4.  Extrinsic  causes :  Aneurysm,  goitre,  enlarged  glands, 
mediastinal  growths,  pericardial  effusion,  tumors  growing 
from  the  bodies  of  the  vertebra,  and  backward  dislocation  of 
the  sternal  end  of  the  clavicle  (modified  from  Rose  and  Car- 
less). 

What  are  the  varieties  of  arterio=venous  aneurysm  and 
state  their  points  of  difference. 

An  arterio-venous  aneurysm  is  either  an  aneurysmal  varix 
or  a  varicose  aneurysm. 

An  aneurysmal  varix  is  a  direct  communication  between 
an  artery  and  a  vein  without  the  interposition  of  a  sac. 

A  varicose  aneurysm  is  an  indirect  communication  between 
an  artery  and  a  vein  with  the  interposition  of  a  sac. 

Give  the  main  points  of  difference  between  acromegaly, 
ostitis  deformans,  and  leontiasis  ossea. 

Acromegaly  occurs  in  young  adults  (20-30;.  It  affects  the 
bones  of  the  hands  and  feet  and  those  of  the  face  (particu- 
larly the  lower  jaw  and  the  nasal  bones) .  The  cranial  bones 
are  not  affected,  with  the  exception  of  the  lower  portion  of 
the  frontal  bones  and  the  margins  of  the  orbits.  The  bones 
of  the  hands  and  feet  are  broader,  but  there  is  no  increase  in 
their  length.  Microscopically  the  osseous  structure  does  not 
differ  from  that  of  normal  bone. 

Ostitis  deformans  begins  moi*e  commonly  in  men  past  mid- 
dle life.  It  affects  the  long  bones  of  the  extremities  and  the 
bones  of  the  cranium.  The  facial  skeleton  shows  little 
change.  Kyphosis  is  present.  Pain  is  present  in  the  early 
stages  of  the  disease,  but,  unlike  other  bone  pains,  it  is  not 
worse  at  night.  The  affected  long  bones  are  increased  in 
length.  The  microscope  reveals  changes  similar  to  those  of 
rarefying  ostitis. 

Leontiasis  ossea  begins  in  early  life,  and  the  extremities  are 


SURGERY.  5S1 

uot  affected.     Both  the  facial  and  the  cranial  bones  are  in- 
volved, the  bones  of  the  jaws  first  becoming  enlarged. 

Give  the  treatment  for  mammary  carcinoma. 

The  treatment  of  mammary  carcinoma  consists  of  the  earli- 
est possible  removal  of  the  entire  breast,  together  with  the 
axillary  and  supraclavicular  glands.  All  these  structures 
should  be  removed  in  one  continuous  piece,  so  that  no  infected 
lymphatic  vessel  is  divided.  Advanced  cases  may  require  the 
removal  of  the  sternal  portion  of  the  pectoralis  major  and  of 
the  pectoralis  minor,  and  in  such  cases  the  entire  mass  re- 
moved should  also  be  in  one  piece.  The  sharpest  knife  ob- 
tainable should  be  used.  The  first  thought  in  the  mind  of  the 
surgeon  should  be  to  remove  all  of  the  cancerous  tissue,  the 
closure  of  the  wound  being  a  consideration  of  secondary 
importance.  Adequate  drainage  should  be  provided,  and 
skin  grafting  should  be  resorted  to  if  sufficient  cutaneous 
covering  cannot  be  safely  left  to  close  the  wound.  Those 
cases  are  to  be  regarded  as  inoperable  in  which  the  disease  is 
no  longer  local.  Palliative  operations  may  be  performed  for 
the  relief  of  pain  in  certain  well-selected  cases. 

Describe  the  various  steps  in  amputation  at  the  wrist 
by  a  long  palmar  flap. 

After  all  aseptic  precautions  have  been  observed,  the  hand 
is  supinated.  the  thumb  is  abducted,  and  an  incision  is  made 
commencing  at  the  styliod  process  of  the  radius  and  extend- 
ing over  the  thenar  eminence  to  the  distal  transverse  palmar 
crease.  This  incision  is  continued  transversely  across  the 
palm  and  then  up  over  the  hypothenar  eminence  to  the  styloid 
process  of  the  ulna.  This  flap  is  now  dissected  away  from 
the  bones,  and  contains  all  of  the  structures  of  the  palm;  the 
rie.xor  tendons  and  large  nerves  should  be  divided  at  the  level 
of  the  wrist  joint  and  removed.  The  hand  is  then  placed  in 
the  pronated  position  and  a  slightly  curved  incision  is  made 
connecting  the  two  styloid  processes,  the  convexity  of  the 
incision    being   directed   downward.      The   extensor    tendons 


582  SURGERY. 

and  the  lateral  and  posterior  ligaments  of  the  wrist  are 
divided  and  the  hand  removed.  After  all  hemorrhage  has 
been  checked  the  palmar  flap  is  brought  over  the  ends  of  the 
bones  and  held  in  position  by  interrupted  sutures  of  silk- 
worm-gut.    An   aseptic   dressing  is  then   applied. 

How  does  ulceration  differ  from  mortification? 

By  ulceration  is  meant  the  molecular  death  of  a  part;  by 
mortification  (or  gangrene)  is  meant  molar  death  or  the 
death  of  the  part  en  masse. 

Differentially  diagnose  phimosis  and  gonorrhea  from 
phimosis  and  subpreputial  chancroid. 

In  phimosis  and  gonorrhea  there  is  no  history  of  a  sore  on 
the  glans  or  prepuce,  the  preputial  swelling  is  at  first  simply 
edematous,  the  discharge  is  usually  purulent,  there  is  no  local- 
ized area  of  hardness  or  tenderness,  chordee  is  frequently 
present,  the  ardor  urinse  is  felt  along  the  entire  urethra, 
vesical  symptoms  are  not  uncommon,  and  bubo  is  very  rare. 

In  phimosis  and  subpreputial  chancroid  there  is  a  history 
ol  a  sore,  the  preputial  swelling  is  due  to  plastic  exudate 
about  the  ulcer,  the  discharge  is  frequently  bloody,  a  localized 
area  of  hardness  or  tenderness  is  usually  present,  true  chordee 
never  occurs,  the  ardor  urinse  is  experienced  only  when  the 
urine  comes  in  contact  with  the  ulcerated  foreskin,  vesical 
symptoms  are  absent  in  uncomplicated  cases,  and  bubo  is 
common. 

Describe  Bassini's  operation  for  the  radical  cure  of  ob= 
lique  inguinal  hernia. 

After  all  aseptic  details  have  been  observed,  an  incision  is 
made  parallel  to  and  one-half  inch  above  Poupart's  ligament. 
This  incision  extends  from  above  the  center  of  Poupart's  lig- 
ament to  the  base  of  the  scrotum,  and  exposes  the  aponeurosis 
of  the  external  oblique  and  the  external  abdominal  ring.  All 
hemorrhage  having  been  checked,  a  grooved  director  is  carried 
into  the  inguinal  canal,  and  the  aponeurosis  of  the  external 
oblique  is  divided  to  a  point  well  above  the  internal  abdominal 


SURGERY.  583 

ring.  The  upper  flap  of  aponeurosis  is  freed  until  the  arching 
fibres  of  the  conjoined  tendon  come  into  view;  the  lower  flap 
is  drawn  down  until  the  shelving  edge  of  Poupart's  ligament 
is  exposed.  The  sac  is  now  separated  from  the  cord  (the  cord 
usually  being  behind  the  sac),  and  this  separation  is  carried 
up  to  the  internal  ring.  The  sac  is  opened,  adhesions  prop- 
perly  dealt  with,  omentum  ligated  in  sections,  and  the  intestine 
returned  to  the  abdominal  cavity.  The  sac  is  then  ligated  at 
a  point  high  up,  just  above  the  internal  ring,  and  the  redund- 
ant portion  cut  ofi:  about  a  centimeter  below  the  ligature. 
The  cord  is  now  held  up  out  of  the  wound  by  a  strip  of  sterile 
gauze,  and  the  conjoined  tendon  sutured  to  the  deep  shelving 
of  Poupart's  ligament  by  four  or  five  sutures.  It  has  been 
advised  to  place  one  suture  above  the  cord,  as  this  is  the  point 
at  which  the  recurrence  is  most  likely  to  occur.  None  of  these 
sutures  should  be  tied  too  tightly,  as  strangulation  of  the 
tissues  greatly  favors  infection  and  interferes  with  the  primary 
union  which  is  absolutely  essential  to  the  success  of  the 
operation.  The  cord  is  now  laid  upon  its  newly-formed  bed 
(after  resection  of  some  of  the  veins  if  necessary),  and  the  cut 
edges  of  the  aponeurosis  of  the  external  oblique  are  united 
by  a  continuous  suture.  Great  care  should  be  taken  to  pre- 
vent any  suture  interfering  with  the  circulation  in  the  cord. 
The  cutaneous  wound  is  then  closed  with  a  subcuticular  stitch 
and  an  aseptic  dressing  applied.  The  deep  sutures  should 
consist  of  kangaroo  tendon,  the  superficial  ones  of  chrorai- 
•cized  cat-gut.  If  the  operator  is  not  sure  of  the  asepticity  of 
the  tendon  or  cat-gut,  silk  sutures  should  be  employed. 

Give  the  differential  diagnosis  of  abscess. 

If  an  abscess  is  present  there  will  be  a  history  of  a  preced- 
ing inflammation,  fluctuation,  a  tendency  to  point,  an  absence 
of  thrill,  an  absence  of  bruit,  a  febrile  temperature  (as  a 
rule) ,  and  an  examination  of  the  blood  usually  reveals  a  poly- 
morphonuclear leukocytosis.  If  the  abscess  lies  over  a  blood- 
vessel it  may  have  an  up-and-down  pulsation,  but  if  the 
abscess  is  pushed  to  one  side  this  pulsation  ceases.     In  such  a 


584  SUBGERY. 

case  the  abscess  will  not  change  in  size  if  pressure  is  made 
upon  the  vessel  above  or  below  the  abscess.  The  exploring 
syringe  reveals  pus. 

Aneurysm:  If  an  aneurysm  is  present  there  will  be  no  his- 
tory of  a  preceding  inflammation,  fluctuation  is  rare,  the 
swelling  preserves  its  fusiform  or  rounded  shape,  showing  no 
tendency  to  point,  thrill  and  bruit  are  present,  the  pulsation 
is  expansile,  the  swelling  cannot  be  moved  from  the  line  of 
the  blood-vessel,  pressure  above  the  aneurysm  decreases  its 
size  and  expansile  force,  pressure  below  the  aneurysm  in- 
creases its  size  and  expansile  force,  there  may  be  a  difference 
in  the  pulse  to  the  distal  side  of  the  aneurysm  as  compared 
with  the  corresponding  vessel  upon  the  opposite  side,  and 
leukocytosis  and  fever  are  absent  (unless  the  sac  is  inflamed). 
The  exploring  syringe  reveals  blood. 

Cysts :  The  overlying  tissues  are  not  edematous,  nor  is  there 
a  history  of  a  preceding  inflammation.  The  exploring  syringe 
is  of  value  in  doubtful  cases, 

Tumoi*s :  The  only  tumor  apt  to  be  confused  with  an  ab- 
scess is  a  rapidly  growing  sarcoma  (small  round  cell).  Al- 
though these  tumors  may  fluctuate,  inflammatory  symptoms 
are  absent,  and  the  exploring  syringe  reveals  a  bloody  fluid. 

Describe  intermediate  and  secondary  hemorrhage,  giv= 
ing  both  preventive  and  curative  treatment  of  each. 

B}'  intermediate  hemorrhage  is  meant  a  hemorrhage  recur- 
ring within  twenty-four  hours  of  an  accident  or  operation. 

Preventive  treatment :  The  proper  method  of  tying  the 
ligatures  (surgeon's  knot),  w^hich  should  include  the  artery 
alone,  and  not  the  surrounding  tissues.  All  bleeding  points 
should  be  carefully  and  completely  controlled  at  the  time  of 
the  accident  or  injury,  and  stimulants  should  not  be  injudi- 
ciously employed. 

Curative  treatment:  Elevation  and  pressure.  If  these 
measures  are  not  successful,  the  wound  should  be  opened  up, 
irrigated  wath  hot  sterile  saline  solution,  and  all  bleeding 
points  tied.     If  ligatures  cannot  be  applied,  the  actual  can- 


SURGERY.  585 

teiy  may  be  euiployed,  or  the  wound  may  be  packed  with 
antiseptic  gauze. 

By  secondary  hemorrhage  is  meant  any  hemorrhage  occur- 
ring in  a  wound  after  the  lapse  of  twenty-four  hours  from 
the  time  of  the  injury  or  operation. 

Preventive  treatment:  Thorough  asepsis,  the  proper  appli- 
cation of  ligatures  to  all  bleeding  points,  and  the  avoidance 
of  the  injudicious  use  of  stimulants. 

Curative  treatment:  This  will  depend  upon  whether  the 
hemorrhage  comes  from  the  end  of  a  divided  artery  (as  in  a 
stump)  or  whether  it  comes  from  an  artery  which  has  been 
ligated  in  its  continuity. 

If  the  hemorrhage  comes  from  the  end  of  a  completely 
divided  artery  (as  in  a  stump),  elevation,  exposure  to  the  air, 
irrigation  with  hot  sterile  saline  solution,  and  firm  bandaging 
may  suffice  in  the  milder  cases.  If  the  hemorrhage  recurs, 
the  wound  must  be  opened  again,  and  the  bleeding  points 
ligated.  If  ligatures  cannot  be  employed  on  account  of  the 
septic  condition  of  the  tissues,  the  actual  cautery  will  be  of 
service.  All  septic  sloughs  should  be  removed  by  the  Volk- 
mann  spoon,  and  the  wownd  swabbed  out  with  carbolic  solu- 
tion (1-20)  or  with  a  solution  of  chloride  of  zinc  (1-12). 
The  wound  should  then  be  dusted  with  iodoform  crystals, 
firmly  packed  with  iodoform  gauze,  and  a  firm  bandage 
applied.  If  the  secondary  hemorrhage  occurs  later  in  the 
case,  the  wound  must  be  opened  up,  the  bleeding  vessel  iso- 
lated from  the  surrounding  structures,  and  ligated  higher  up. 
If  this  is  impossible,  the  artery  must  be  ligated  still  higher 
up,  or  a  re-amputation  performed.  If  the  secondary  hemor- 
rhage occurs  after  a  shoulder  or  hip  amputation,  proximal 
ligation  is  the  only  measure  to  rely  upon  should  the  local 
treatment  fail. 

If  the  hemorrhage  comes  from  an  artery  which  had  been 
ligated  in  its  continuity,  the  same  local  treatment  should  be 
adopted  as  in  the  former  instance.  If  this  is  unsuccessful, 
tlip   trcatmout  will   depend   upon   the  situation   ot"  the  vessel. 


586  SURGERY. 

If  the  vessel  is  in  the  trunk  (iliac)  or  neck  (carotid)  the 
wound  must  be  opened  up,  the  artery  again  ligated  above  and 
below,  and  the  septic  condition  of  the  tissues  combated  by 
packing  with  antiseptic  gauze.  If  this  fails,  and  proximal 
ligation  is  impossible,  pressure  will  be  the  last  resort.  In 
the  arm,  if  cold,  pressure  and  elevation  are  without  effect, 
the  original  wound  must  be  enlarged,  and  the  vessel  tied 
above  and  below.  If  the  hemorrhage  still  continues,  the 
artery  must  be  exposed  and  ligated  higher  up  through  an 
independent  incision,  or  amputation  will  have  to  be  per- 
formed. In  the  leg,  a  second  ligature  at  a  higher  point  is  of 
questionable  value  on  account  of  the  poorer  collateral  circu- 
lation. Should  it  control  the  hemorrhage,  gangrene  will  re- 
sult, and  consequently  amputation  should  at  once  be  per- 
formed if  the  local  measures  are  unsuccessful. 

State  the  difference  between  sthenic  and  asthenic  in= 
flammatory  fever. 

Sthenic  inflammatory  fever  occurs  in  the  young  and  in  the 
robust.  It  rarely  commences  with  a  chill,  the  temperature 
rises  to  102  degrees  or  103  degrees  F.,  delirium  if  present  is 
maniacal,  the  pulse  is  full  and  strong,  the  skin  is  hot  and  dry, 
and  constipation  is  present. 

Asthenic  inflammatory  fever  occurs  in  the  aged  and  in  the 
debilitated.  It  usually  commences  with  a  chill,  the  temper- 
atures rises  to  104°  or  105°  F.,  the  delirium  is  low  and  mutter- 
ing, the  pulse  is  rapid  and  weak,  the  skin  is  cold  and  clammy, 
and  diarrhea  is  present. 

Differentiate  dislocation  of  the  head  of  the  femur  from 
fracture  of  its  neck,  and  give  main  essentials  of  treatment 
of  each. 

Dorsal  Dislocation.  Intracapsular  Fracture. 

Inversion  of  foot.  Eversion  of  foot. 

Immobility.  Preternatural  mobility. 

Head  of  femur  not  felt  in  its  na-       Head  of  femur  felt  in  its  natural 
tural  position.  position. 


SURGERY 


587 


The  buttocks  of  the  affected  side 
are  unduly  prominent,  due  to 
the  presence  of  the  head  of  the 
dislocated  bone. 

Crepitus  is  absent. 

Immediate  shortening  of  two  or 
three  inches. 

Rarely  occurs  after  forty-five,  and 

more  commonly  in  the  male. 
Violence    usually    considerable. 


Flattening  of  hip,  the  great  tro- 
chanter moving  in  an  arc  of 
smaller  radius,  and  relaxation 
of  the  ilio-tibial  band. 

Crepitus  may  be  elicited  (unless 
impaction  is  present). 

Immediate  shortening  of  a  half- 
inch,  consecutive  shortening  of 
two  or  three  inches. 

Much  more  common  in  advanced 
life  and  in  the  female. 

Violence   usually  trivial. 


Treatment. 


Reduction  by  flexion  of  leg  upon 
thigh  (for  leverage),  flexion  of 
thigh  upon  abdomen  (to  relax 
Y-ligament),  external  circum- 
duction, and  extension.  When 
reduction  has  been  effected,  the 
knees  should  be  bandaged  to- 
gether, and  the  patient  kept  in 
bed  for  two  weeks. 


Reduction  by  extension  and  coun- 
ter-extension. Buck's  extension 
should  be  permanently  employed. 
A  sandbag  extending  from  the 
axilla  to  the  external  malleolus 
should  then  be  placed  upon  the 
outer  side  of  the  extremity,  and 
one  extending  from  the  groin  to 
the  internal  malleolus  upon  the 
inner  side  of  the  extremity. 

In  some  cases  it  may  be  advisable 
to  apply  a  plaster  cast  over  the 
abdomen  and  over  the  injured 
extremity  to  below  the  knee, 
and  to  allow  the  patient  to 
change  her  position.  In  other 
cases  the  general  condition  of 
the  patient  makes  it  imperative 
to  absolutely  disregard  the  frac- 
ture. 


Describe  a  method  of  amputation  of  the  thigh. 

The  method  giving  the  best  results  will  generally  be  a  flap 
amputation  through  the  skin  and  a  circular  amputation 
through  the  muscles  {mixed  method).  After  all  aseptic  pre- 
cautions have  been  observed,  and  a  tourniquet  properly  ap- 
plied, the  surgeon  takes  his  position  upon  the  right  side  of  the 
extremity  to  be  amputated  and  makes  a  straight  incision  upon 


588  SURGERY. 

either  side  of  the  thigh.  These  incisions  commence  at  the 
level  at  which  the  bone  is  to  be  divided;  they  are  as  long  as 
the  diameter  of  the  limb  at  their  point  of  origin,  and  they 
divide  the  skin  and  subcutaneous  connective  tissue.  The 
lower  ends  of  these  incisions  should  be  connected  by  a  trans- 
verse cut  of  similar  depth,  and  the  corners  of  the  flap  rounded 
off.  The  centers  of  the  two  incisions  should  now  be  joined 
by  a  posterior  transverse  incision,  the  cornel's  being  rounded 
oft'  as  before.  The  anterior  flap  is  now  raised,  and  consists  of 
nothing  but  skin  and  subcutaneous  fat,  excepting  at  its  base, 
where  a  certain  amount  of  muscular  tissue  should  be  included. 
The  posterior  flap  is  then  dissected  up,  and  should  consist  of 
nothing  but  skin  and  subcutaneous  fat  throughout.  The 
muscles  are  now  to  be  divided  by  a  circular  sweep  of  the  knife. 
An  assistant  retracts  the  muscular  tissue,  a  cuff  of  periosteum 
is  raised,  and  the  bone  is  sawn  through  as  high  up  in  the 
wound  as  possible  (about  one  and  one-half  inches  above  the 
angles  of  junction  of  the  flaps).  After  the  main  vessels  have 
been  secured  the  tourniquet  should  be  loosened  and  all  bleed- 
ing points  caught  and  ligated.  Large  nerves  are  drawn  out 
and  divided  with  scissors  at  the  highest  possible  level,  any 
projecting  tendons  are  retrenched,  and  capillary  hemorrhage 
is  checked  by  hot  sterile  saline  solution.  The  muscular  tissue 
may  then  be  sutured  over  the  end  of  the  bone  if  desired,  and 
the  edges  of  the  flap  united  by  interrupted  sutures.  The 
operation  is  concluded  by  the  application  of  an  aseptic 
dressing. 

Give  the  symptoms  and  treatment  of  luxation  of  the 
eIbow=joint  with  special  reference  to  the  prevention  of 
ankylosis. 

The  most  frequent  dislocation,  that  of  both  bones  back- 
ward will  be  selected. 

Symptoms :  The  elbow  is  flexed,  the  forearm  is  midway  be- 
tween pronation  and  supination,  and  slight  motion  causes  great 
pain.  The  olecranon  and  the  head  of  the  radius  may  be  felt 
posteriorly    while    the    lower    extremity    of    the    humerus    is 


SURGERY.  589 

prominent   anteriorly.      The   forearm   is  shortened   and   the 
olecranon  projects  above  a  line  connecting  the  two  condyles. 

Treatment :  The  patient  is  seated  in  a  chair.  The  surgeon 
places  his  knee  in  the  bend  of  the  elbow  and  makes  pressure 
against  the  lower  end  of  the  humerus,  simultaneously  fixing 
the  forearm  by  grasping  it  just  above  the  wrist.  After 
maintaining  this  pressure  for  a  short  time  the  forearm  is 
slowly  but  forcibly  flexed  upon  the  arm,  the  knee  of  the 
surgeon  acting  as  a  fulcrum  and  disengaging  the  coronoid 
process  of  the  ulna  from  the  trochlear  surface  of  the  hu- 
merus. The  elbow  is  then  put  upon  an  angular  splint  or  en- 
cased in  a  plaster  of  Paris  bandage  for  two  weeks  after 
Avhich  passive  motion  and  massage  should  be  employed  daily 
to  prevent  ankylosis.  A  lighter  splint  should  be  worn  be- 
tween the  periods  of  massage  for  at  least  one  week  longer. 

Outline  the  treatment  for  irreducible  umbilical  hernia. 

If  any  contra-indication  to  operation  exists  and  there  is  no 
risk  of  strangulation  some  retentive  apparatus  may  be  worn. 

Practically  all  of  these  cases,  however,  should  be  operated. 
The  entire  hernial  site  is  excised,  the  contents  are  reduced,  and 
the  abdominal  wound  is  closed  layer  by  layer.  The  patient 
should  be  kept  upon  her  back  until  the  union  is  firm  and 
an  abdominal  belt  may  be  worn  for  several  months. 

Describe  the  operation  of  perineal  prostatectomy. 

After  all  aseptic  precautions  have  been  carried  out  the 
patient  is  placed  in  the  lithotomy  position  and  an  inverted 
V-shaped  incision  is  made  through  the  skin  and  superficial 
fascia,  the  apex  of  the  V  being  over  the  posterior  part  of 
the  bulb  and  the  branches  extending  to  a  point  midway  be- 
tween the  anus  and  the  tuberosity  of  the  ischium.  The  central 
tendon  of  the  perineum  and  the  recto-urethralis  muscle  are 
divided  so  that  the  rectum  may  easily  be  retracted  backward, 
giving  free  access  to  the  membranous  urethra  and  the  apex 
of  the  prostate  gland.  The  membranous  urethra  is  incised 
longitudinally  upon  a  grooved  staff,  the  edges  are  caught  with 


590  SURGERY. 

forceps  and  Young's  prostatic  tractor  is  introduced  and 
opened  out.  By  pulling  upon  the  tractor  the  prostate  is 
brought  weU  down  into  the  wound  and  may  be  readily 
enucleated.  By  making  two  divergent  incisions  into  the  pros- 
tate as  advised  by  Young,  the  ejaculatory  ducts,  and  the  floor 
of  the  urethra  may  be  spared.  If  a  median  bar  or  lobe  be 
present  it  may  be  made  to  project'  into  one  of  the  lateral 
cavities  and  also  enucleated.  In  some  cases  the  finger  may  be 
substituted  for  the  prostatic  tractor  with  advantage. 

Describe  any  one  of  the  dislocations  of  the  shoulder= 
joint. 

Subcoracoid  dislocation.  There  is  a  flattening  of  the 
shoulder- joint,  the  head  of  the  humerus  being  felt  beneath  the 
coracoid  process.  The  vertical  circumference  around  the 
axilla  is  increased  (Callaway's  sign).  A  ruler  or  straight- 
edge may  be  brought  in  contact  with  the  top  of  the  acromion 
and  the  external  condyle  of  the  humerus  simultaneously 
(Hamilton's  sign) .  If  the  hand  of  the  dislocated  extremity  be 
placed  upon  the  sound  shoulder  the  elbow  cannot  be  approxi- 
mated to  the  chest-wall  (Dugas'  sign).  The  elbow  is  away 
from  the  side  and  slightly  posterior.  The  axis  of  the  arm  is 
altered.  The  patient  is  unable  to  touch  the  top  of  his  head 
with  the  hand  of  the  dislocated  extremity. 

Give  the  diagnostic  symptoms  and  the  surgical  treat- 
ment  of  congenital  inguinal  hernia. 

Symptoms :  The  sudden  appearance  of  an  inguinal  swelling 
which  soon  extends  into  the  scrotum.  This  swelling  gives 
an  impulse  on  coughing  and  when  reduced  flops  back  with  a 
gurgle.  It  is  not  translucent.  The  hernia  is  always  of  the 
indirect  variety.  The  hernial  contents  can  not  be  differenti- 
ated from  the  testicle  as  readily  as  in  a  hernia  of  the  ac- 
quired type.  In  a  congenital  inguinal  hernia,  the  testicle  is 
at  the  bottom  of  the  scrotum  while  in  the  acquired  variety  the 
testicle  is  on  the  posterior  wall  of  the  scrotum  at  the  junction 
of   tlie   middle   with   the   lower   third.     As   in   the   acquired 


SURGERY.  591 

variety,  the  symptoms  will  also  depend  upon  the  nature  of 
the  hernial  contents.  A  "congenital  hernia"  may  develop  at 
any  period  of  life,  it  is  only  the  sac  which  is  present  at  birth. 
Surgical  treatment:  Bassini's  operation  (described  else- 
where). Instead  of  removing  the  entire  sac  as  in  a  typical 
Bassini.  a  tunica  vaginalis  is  fashioned  from  its  lower  por- 
tion. The  upper  portion  of  the  sac  is  ligated  or  sutured  as  in 
the  ordinary  operation  for  the  radical  cure  of  the  acquired 
variety  of  inguinal  hernia. 

Give  the  symptoms  and  treatment  of  acute  ischiorectal 
abscess. 

Symptoms :  Severe  stabbing  pain  at  one  side  of  the  rectum 
which  is  increased  by  defecation  and  digital  examination. 
The  patient  is  unable  to  sit  squarely  upon  the  buttocks  but 
rests  upon  the  healthy  side,  allowing  the  inflamed  area  to  pro- 
ject beyond  the  edge  of  the  chair.  Inspection  reveals  a 
hard  brawny  swelling  at  the  side  of  the  anus,  which  is  ex- 
quisitely tender;  the  overlying  skin  is  reddened  and  edematous. 
The  swelling  soon  softens  and  exhibits  fluctuation  upon  pal- 
pation.    A  considerable  amount  of  fever  is  usually  present. 

Treatment:  Free  incision  and  the  maintenance  of  gauze 
drainage  so  that  the  cavity  will  heal  up  from  the  bottom. 

Give  symptoms  and  treatment  of  gun=shot  and  stab= 
wounds  of  the  abdominal  wall  involving  the  intestines. 

Symptoms:  The  presence  of  a  wound  of  entrance  and  pos- 
sibly also  one  of  exit.  The  most  characteristic  symptoms  of 
a  wound  of  the  intestine  are  localized  pain  and  rigidity  of  the 
overlying  muscles.  The  other  symptoms  are  so  variable  that 
small  dependence  may  be  placed  upon  them.  Shock  may  or 
may  not  be  present. 

Treatment :  AVhile  a  masterly  inactivity  may  be  justifiable 
in  military  practice,  there  is  but  one  course  for  a  competent 
abdominal  surgeon  to  pursue  when  he  can  give  his  patient  the 
advantages  of  thorough  asepsis.  After  all  aseptic  precau- 
tions have  been  insured,  the  wound  of  entrance  should  be  en- 


592  SURGERY. 

larged  though  it  is  usually  best  to  make  a  median  incision  of 
sufficient  length  to  allow  the  operator  to  quickly  inspect  the 
entire  length  of  the  intestinal  tract.  The  small  intestine 
should  be  followed  from  one  end  to  the  other,  the  assistant 
replacing  the  bowel  as  soon  as  the  surgeon  finishes  his  ex- 
amination so  that  only  a  single  coil  is  exposed  at  any  one 
time.  The  large  intestine  is  then  to  be  quickly  but  thoroughly 
examined.  The  possibility  of  an  extraperitoneal  wound 
should  also  be  remembered.  All  perforation  should  be 
quickly  closed  by  Lembert  or  purse-string  sutures.  If  sev- 
eral perforations  are  close  together,  time  may  be  gained  by 
resecting  the  gut  and  making  an  end-to-end  anastomosis  by 
means  of  a  Murphy  button.  If  more  than  half  of  the  lumen 
would  be  encroached  upon  by  repairing  a  perforation,  resec- 
tion is  advisable.  If  these  eases  are  operated  upon  early 
( within  four  hours)  irrigation  is  not  necessary.  If  extravasa- 
tion has  occurred,  however,  the  peritoneal  cavity  must  be 
thoroughly  irrigated  with  a  large  quantity  of  normal  saline 
solution.  Drainage  may  or  may  not  be  necessary.  Thorough- 
ness and  rapidity  are  indispensable  to  the  success  of  the 
operation. 

Give  the  symptoms  and  treatment  of  fracture  of  the 
base  of  the  skull. 

The  general  symptoms  may  be  those  of  concussion,  com- 
pression or  laceration  of  the  brain. 

The  local  symptoms  will  depend  upon  the  cerebral  fossa 
involved. 

In  the  anterior  fossa,  if  the  orbital  plate  be  involved,  there 
will  be  subconjunctival  ecchymosis  and  possibly  a  certain  de- 
gree of  proptosis  as  the  eyeball  may  be  pushed  forward  by 
retrobulbar  hemorrhage.  If  the  cribriform  plate  of  the  eth- 
moid be  involved,  blood  and  cerebrospinal  fluid  will  escape 
from  the  nose.     Loss  of  smell  may  be  present. 

In  the  middle  fossa  those  signs  will  be  present  which  are 
described  upon  page  622. 

In  the  posterior  fossa  the  symptoms  are  ill  defined.     There 


SURGERY.  593 

may  be  bleeding  from  the  mouth  or  the  blood  may  be  swal- 
lowed and  subsequently  vomited.  Deep-seated  ecchymosis 
may  become  manifest  among  the  muscles  at  the  back  of  the 
neck.     The  cranial  nerves  are  rarely  involved. 

Treatment:  Absolute  rest  in  bed.  Perfect  quiet,  the  exclu- 
sion of  light  and  sound,  a  restricted  diet  and  the  administra- 
tion of  a  brisk  mercurial  purge.  The  external  auditory 
meatus  should  be  thoroughly  disinfected,  plugged  with  anti- 
septic gauze,  and  further  protected  by  an  antiseptic  pad  over 
the  ear  of  the  affected  side.  The  nares  and  throat  should  be 
kept  as  clean  as  possible  by  the  use  of  an  antiseptic  spray. 

Describe  the  varieties  and  the  treatment  of  fractures 
of  the  patella. 

The  ordinary  fracture  of  the  patella  is  due  to  muscular  ac- 
tion. It  is  transverse,  almost  always  complete,  and  the  frag- 
ments are  usually  distinctly  separated. 

The  safest  method  of  treatment  is  to  fix  the  knee-joint,  re- 
duce the  intra-articular  effusion  by  evaporating  lotions,  pres- 
sure, or  aspiration  and  then  to  hold  the  fragments  in  position 
by  the  use  of  Agnew's  posterior  splint,  adhesive  plaster,  and 
bandages.     This  treatment  can  effect  only  a  fibrous  union. 

The  only  way  in  which  a  perfect  result  may  be  secured  is 
by  making  a  free  longitudinal  incision  over  the  fracture,  re- 
moving the  clots  and  fibrous  tissue  from  between  the  ends  of 
the  fragments,  drilling  the  fragments  obliquely,  and  wiring 
them  together.  If  rigid  asepsis  is  not  secured  the  patient 
may  lose  his  leg  or  even  his  life.  This  is  the  treatment  to  be 
adopted  in  young  active  patients  whose  livelihood  depends 
upon  a  perfect  functional  result.  If  the  patient  be  past  middle 
age  and  of  sedentary  habits  the  treatment  with  the  posterior 
splint  and  the  resulting  fibrous  union  may  be  perfectly  satis- 
factory to  him  if  he  does  not  care  to  a.ssume  the  risk  of  the 
operative  procedure. 

The  second  and  rarer  variety  of  fracture  of  the  patella  is 
that  due  to  dii-ect  violence.  It  is  usually  stellate  but  may  be 
oblique,  longitudinal,  or  even  transverse.  It  is  frequently  in- 
38 


594  SURGERY. 

complete  and  the  fibrous  expansion  of  the  quadriceps  may  not 
be  torn,  so  that  the  fragments  are  not  displaced.  The  over- 
lying tissues  are  bruised  and  swollen. 

The  posterior  splint  and  evaporating  lotions  usually  give 
good  results  in  these  cases.  They  are  not  so  favorable  for 
operation  on  account  of  the  contusion  of  the  overlying 
tissues.  It  is  exceptional  that  operation  is  required  for  a 
fracture  of  this  type. 

Describe  the  treatment  for  fracture  of  the  shaft  of  the 
femur  at  the  middle  third. 

These  fractures  are  to  be  treated  with  a  long  external  splint 
provided  with  a  foot  piece  (Desault's),  by  three  shorter  splinta 
applied  to  the  circumference  of  the  thigh,  and  by  extension. 
The  bed  should  be  hard  and  firm.  The  foot  is  firmly  ban- 
daged to  the  foot-piece  by  a  figure-8  bandage,  all  bony 
prominences  being  carefully  padded.  The  short  splints  are 
then  applied  to  the  anterior,  inner  and  posterior  aspects  of  the 
thigh  and  should  extend  to  the  knee-.joint  or  slightly  beyond 
it.  They  are  to  be  held  in  position  by  two  broad  pieces  of 
elastic  webbing.  An  assistant  now  makes  traction  upon  the 
splint  until  the  deformity  is  reduced  and  the  extremity  is  of 
the  same  length  as  its  fellow.  The  pieces  of  webbing  are 
then  tightened  and  secured,  and  the  upper  portion  of  the 
splint  is  fixed  to  the  body  of  the  patient,  preferably  by  a 
broad  piece  of  muslin  which  is  sewn  to  the  splint,  passed  be- 
neath the  body  of  the  patient  and  then  brought  back  to  the 
splint  where  it  is  secured.  This  broad  piece  of  muslin  pre- 
vents anterior  displacement  of  the  splint.  In  addition  to- 
this,  most  surgeons  prefer  to  make  permanent  extension,  the 
stirrup  for  which  is  applied  before  the  extremity  is  fixed  upon 
the  external  splint.  Union  should  be  secured  in  about  eight 
weeks  but  no  weight  should  be  borne  upon  the  extremity  until 
the  end  of  the  twelfth  week. 

Describe  a  cartilaginous  tumor.  Where  are  such 
growths  most  commonly  found? 

A  cartilaginous  tumor  (chrondroma)   is  a  tumor  composed 


SURGERY.  595 

of  hyaline  cartilage.  They  are  most  commonly  found  in  con- 
nection with  some  of  the  long  bones,  particularly  the  meta- 
carpal bones  and  phalanges  of  the  hand,  the  humerus,  the 
tibia,  the  femur,  and  rarely  the  ribs.  They  may  also  occur 
in  the  parotid  gland,  testicles,  breast,  or  thyroid  gland,  but 
in  these  situations  they  are  usually  associated  with  some  other 
variety  of  tumor. 

Mention  the  inflammatory  diseases  of  bone. 

Periostitis,  ostitis,   and  osteomyelitis. 

What  is  inflammation?  How  does  inflammation  extend 
and  how  may  it  terminate? 

■'Inflammation  is  the  succession  of  changes  which  occur  in 
a  living  tissue  when  it  is  injured,  provided  that  the  injury  is 
not  of  such  a  degree  as  to  at  once  destroy  its  structure  and 
vitality."     (Burdon  Sanderson.) 

Inflammation  may  extend  by  continuity,  by  contiguity, 
through  the  blood  vessels,  and  through  the  lymphatics. 

Inflammation  may  terminate  by  resolution,  retrogression, 
suppuration,  ulceration,  or  gangrene. 

State  the  distinction  between  the  antiseptic  and  aseptic 
wound  treatment. 

In  antiseptic  wound  treatment  an  effort  is  made  to  destroy 
the  germs  in  a  wound,  as  well  as  to  prevent  the  entrance  of 
more  bacteria.  The  greatest  reliance  is  placed  upon  chemical 
agents. 

In  aseptic  wound  treatment  an  effort  is  made  to  prevent  the 
entrance  of  germs  into  a  wound.  The  greatest  reliance  is 
placed  upon  mechanical  purification  and  upon  sterilization 
by  heat. 

Mention  the  general  characteristics  of  a  benign  tumor 
as  distinguished  from  a  malignant  tumor. 

Benign  tumors,  in  contradistinction  to  malignant  tumors, 
are  usually  encapsulated,  grow  slowly,  do  not  infiltrate,  are 
rot  painful  (except  by  pressure),  do  not  give  metastasis,  do 


596  SURGERY. 

not  recur  upon  removal,  produce  no  cachexia,  and  do  not  cause 
death  (except  by  location). 

What  are  the  indications  for  ligature  of  the  lingual 
artery?  Give  the  steps  of  the  operation,  omitting  aseptic 
details. 

The  lingual  artei-y  is  most  frequently  tied  as  a  preliminary 
procedure  to  removal  of  the  tongue.  Other  indications  for 
its  ligation  are  to  control  hemorrhage  from  the  artery  or  its 
branches,  to  check  the  growth  of  advanced  carcinoma  of  the 
tongue,  and  certain  cases  of  macroglossia. 

The  patient  should  be  on  his  back,  his  shoulders  raised,  and 
his  head  extended  and  turned  to  the  opposite  side.  Starting 
just  below  the  symphysis  of  the  chin,  an  incision  is  made 
w^hich  passes  dowTiward  and  outward  to  the  greater  cornu  of 
the  hyoid  bone,  and  then  upward  to  the  angle  of  the  jaw, 
ending  at  about  the  level  of  commencement  of  the  incision, 
but  not  endangering  the  facial  artery.  This  incision  divides 
the  integument,  both  layers  of  the  superficial  fascia  with  the 
enclosed  platysma,  and  exposes  a  portion  of  the  submaxillary 
gland.  The  deep  fascia  covering  the  submaxillary  gland  is 
now  incised  and  the  gland  loosened  and  held  up  by  a  retractor. 
"We  have  now  exposed  Lesser 's  triangle,  formed  by  the  hypo- 
glossal nerve  above  and  the  two  bellies  of  the  digastric  muscle 
below.  The  floor  of  this  triangle  is  formed  by  the  hyoglossus 
muscle.  The  stylo-hyoid  and  the  tendon  of  the  digastric  are 
now  drawn  downward,  the  lingual  vein  and  the  hypoglossal 
nerve  are  drawn  upward,  and  an  incision  is  carefully  made 
through  the  hyoglossus  muscle  just  above  the  hyoid  bone.  In 
making  this  last  incision,  which  exposes  the  artery,  care  must 
be  taken  to  avoid  wounding  the  middle  constrictor  and  con- 
sequently opening  the  pharynx.  The  submaxillary  gland 
and  its  duct  must  also  be  protected  from  injury  lest  a  salivary 
fistula  result.  The  aneurysm  needle  is  now  passed  about  the 
artery,  the  ligature  tied,  the  external  wound  sutured,  and  an 
aseptic  dressing  applied.  The  artery  may  also  be  secured 
before  it  passes  beneath  the  hyoglossus,  and  the  danger  of 
opening  the  pharynx  is  thus  greatly  lessened. 


SURGERY.  597 

Name  the  different  varieties  of  malignant  tumors. 

Sarcoma  (round,  spindle,  and  giant-cell,  melanotic,  alve- 
olar, lympho-sarcoma,  and  endothelioma)  and  carcinoma 
(epithelioma,  scirrhous,  encephaloid,  melanotic,  and  colloid). 

Wliat  are  the  chief  affections  of  the  scrotum? 

Intertrigo,  eczema,  erysipelas,  eechymosis,  edema,  chancre, 
chancroid,  syphilitic  eruptions,  tubercular  ulceration,  ele- 
phantiasis (lymph-scrotum),  urinary  fistula,  tubercular  si- 
nuses, gangrene,   lipoma,  sebaceous  cyst,  and  epithelioma. 

What  other  methods  beside  the  use  of  the  knife  are 
employed  to  remove  a  carcinoma  from  superficial  sur- 
faces? 

Caustics  and  the  X-rays. 

Name  the  principal  operations  for  stone  in  the  bladder. 

Perineal  lithotomy,  supra-pubic  lithotomy,  and  litholapaxy. 
Name  the  different  varieties  of  benign  tumors. 

Lipoma,  fibroma,  chondroma,  osteoma,  glioma,  myxoma, 
angioma,  lymphangioma,  myoma,  neuroma,  adenoma,  and 
papilloma. 

Relate  the  causes  of  intestinal  obstruction. 

Acute  obstruction:  1.  Strangulation  by  bands,  adhesions 
or  apertures;  2.  Volvulus;  3.  Impaction  of  foreign  bodies; 
4.  Kinking  of  the  gut  (rare);  5.  Acute  intussusception;  6. 
The  termination  of  a  chronic  obstruction. 

Chronic  obstruction :  1.  Impaction  of  feces,  gall-stones,  for- 
eign bodies ;  2.  Intestinal  affections,  such  as  stricture,  tumors, 
angulation  of  the  gut  from  contraction  of  adhesions,  matting 
together  of  intestinal  coils;  3.  Compression  of  the  intestine 
by  tumors  or  exudates  outside  of  the  bowel. 

Describe  the  ligation  of  the  femoral  artery  at  cny 
selected  point. 

Ligation  at  the  apex  of  Scarpa's  triangle.  The  line  of  the 
artery  is  from  a  point  midway  between  the  anterior-superior 


598  SURGERY. 

spine  of  the  ilium  and  the  symphysis  pubis  to  the  adductor 
tubercle  on  the  inner  condyle  of  the  femur.  The  patient 
should  be  on  his  back,  with  the  thigh  abducted,  rotated  out- 
ward, and  slightly  flexed.  After  all  aseptic  details  have  been 
carried  out.  an  incision  is  commenced  three  inches  below  Pou- 
part's  ligament  and  carried  downward  for  about  three  inches 
in  the  line  of  the  artery,  dividing  the  skin,  superficial  fascia, 
a,nd  fascia  lata.  If  the  lymphatic  glands  are  exposed  they 
may  be  held  to  one  side  or  removed.  In  making  the  incision 
the  internal  saphenous  vein  should  not  be  wounded.  The 
sartorius  muscle  should  now  be  located,  and  beneath  this  mus- 
cle the  artery  will  be  found.  Remember  that  the  fibers  of  the 
sartorius  run  downward  and  inward,  while  those  of  the 
adductor  longus  run  downward  and  outward.  The  sheath 
should  be  opened  upon  the  outer  side  and  the  crural  branch 
of  the  genito-crural  nerve  and  the  long  saphenous  nerve 
avoided.  The  aneurysm  needle  is  to  be  passed  from  within 
outward.  The  cutaneous  wound  is  then  sutured  and  asep- 
tic dressing  applied. 

What  are  the  chief  surgical  diseases  of  the  groin? 

Inguinal  hernia,  femoral  hernia,  lymphadenitis,  and  en- 
cysted hydrocele  of  the  cord.  Psoas  abscess,  hip  disease,  and 
pelvic  abscess  may  give  rise  to  swellings,  which  are  first 
observed  in  the  groin. 

How  are  wounds  classified? 

Incised,  lacerated,  contused,  punctured,  poisoned,  and  gun- 
shot. They  may  also  be  divided  into  septic  and  aseptic. 
Wounds  in  the  vicinity  of  great  serous  cavities  are  divided 
into  penetrating  and  non-penetrating.  Wounds  are  also 
spoken  of  as  being  either  subcutaneous  or  open. 

Describe  the  anastomosis  which  takes  place  after  liga= 
tion  of  the  femoral  artery  at  its  middle  third. 

The  profunda  femoris  anastomoses  with  the  articular 
branches  of  the  popliteal  and  with  the  tibial  recurrent;  the 
comes    nervi    ischiadici    anastomoses    with    the    perforating 


SURGERY.  599 

branches   of   the   profunda  femoris   and  with   the   articular 
branches  of  the  popliteal  and  tibial  recurrent. 

Where  should  the  opening  be  made  in  order  to  reach  the 
antrum  in  a  case  of  abscess  of  the  middle  ear? 

In  the  posterior  superior  angle  of  the  suprameatal  triangle 
of  Macewen,  which  is  bounded  above  by  the  posterior  root  of 
the  zygoma,  in  front  by  the  upper  and  posterior  segment  of 
the  osseous  external  meatus,  and  behind  by  a  line  drawn  tan- 
gent to  the  bony  meatus  and  almost  at  right  angles  to  the 
posterior  root  of  the  zygoma.  The  chisel  is  to  be  directed 
slightly  forward  to  avoid  wounding  the  sigmoid  sinus,  and 
•care  should  be  taken  to  avoid  injury  to  the  facial  nerve. 

What  agents  are  employed  for  the  production  of  local 
anesthesia? 

Ice  and  salt,  carbolic  acid,  ethyl  chloride,  cocaine  (intra- 
dermic,  infiltration,  perineural  and  paraneural  methods), 
eucaine,  and  nirvanin. 

What  are  the  causes  of  secondary  hemorrhage? 

Chief  cause :  Septic  arteritis. 

Contributory  causes:  1.  Early  absorption  of  ligature;  2. 
Faulty  application  of  ligature;  3.  Ligature  too  near  a  col- 
lat^'ral  branch;  4.  A  diseased  condition  of  the  arterial  wall; 
5.  A  state  of  the  blood  unfavorable  to  wound  repair  (albu- 
minuria or  diabetes)  ;  6.  Increased  blood  pressure  (plethora. 
Bright 's  disea-se,  fever,  excitement,  injudicious  administra- 
tion of  stimulants). 

What  are  the  causes  of  esophageal  stricture? 

Congenital  narrowing,  the  cicatricial  contraction  of  healed 
ulcers  (due  to  the  ingestion  of  corrosive  liquids  or  to  syphilis), 
carcinoma,  polypoid  tumors  projecting  from  the  mucosa,  and 
external  pressure  (aneurism,  goitre,  sarcoma  of  glands  or  of 
vertebr*,  pericardial  effusion).  Strictures  near  the  cardiac 
orifice  may  arise  from  the  healing  and  contraction  of  a  gastric 
ulcer. 


600  SURGERY. 

At  what  point  is  paracentesis  thoracis  preferably  per= 
formed? 

At  the  most  dependent  point  of  the  effusion.  The  site 
usually  selected  is  in  the  seventh  or  eighth  interspace  just 
below  the  angle  of  the  scapula  or  in  the  posterior  axillary  line. 

What  are  the  predisposing  and  what  are  the  exciting 
causes  of  abdominal  hernia? 

Predisposing  causes :  Early  life,  male  sex,  occupations  de- 
manding great  muscular  exertion,  structural  defects  (elonga- 
tion of  the  mesentery,  a  patent  funicular  process),  heredity, 
relaxation  of  the  abdominal  wall  from  disease,  weakening 
certain  portions  of  the  abdominal  wall  by  injury  or  operation, 
phimosis,  pertussis,  bronchitis,  urethral  stricture  and  consti- 
pation. 

Exciting  cause:  Any  increase  of  the  intra-abdominal  pres- 
sure. 

What  are  angiomata? 

Angiomata  are  tumors  composed  of  blood  vessels,  some  of 
which  are  of  new  formation. 

Define  volvulus  and  give  its  treatment. 

By  volvulus  is  meant  a  twisting  of  the  gut  in  such  a  manner 
that  the  intestinal  lumen  is  occluded  and  the  circulation  of 
the  bowel  affected.  Treatment:  Celiotomy.  An  attempt  may 
be  made  to  untwist  the  intestine,  but  this  is  usually  impos- 
sible. If  the  attempt  succeeds  a  recurrence  of  the  condition 
should  be  guarded  against  by  shortening  the  mesentery.  If 
the  attempt  fails  one  of  three  courses  may  be  pursued: 

1.  An  anastomosis  may  be  performed  between  the  bowel 
above  and  that  below  the  volvulus. 

2.  Resection  of  the  portion  of  intestine  involved,  followed 
by  circular  enterorrhaphy. 

3.  The  making  of  an  artificial  anus.  If  the  large  intestine 
is  involved,  as  is  usually  the  case,  the  latter  course  is  prob- 
ably the  best  one. 


SURGERY.  601 

What  is  an  abscess? 

An  abscess  is  a  circumscribed  collection  of  pus  in  a  cavity 
of  abnormal  formation. 

How  does  a  carbuncle  differ  from  a  furuncle? 

A  carbuncle  is  a  gangrenous  inflammation  commencing  in 
the  subcutaneous  tissues  and  extending  to  the  skin.  Car- 
buncles are  usually  single,  occur  most  commonly  after  middle 
life,  show  a  predilection  for  the  back  of  the  neck  or  inter- 
scapular region,  and  discharge  through  more  than  one  open- 
ing. They  are  larger,  flatter,  and  accompanied  by  greater 
constitutional  disturbances  than  are  furuncles. 

A  furuncle  is  a  gangrenous  inflammation  commencing  in 
the  skin  and  extending  to  the  subcutaneous  tissues.  Fur- 
uncles are  usually  multiple,  occur  most  commonly  during 
adolescence  and  early  adult  life,  show  no  predilection  for  any 
portion  of  the  body,  and  discharge  through  a  single  central 
opening.  They  are  smaller,  more  conical,  and  accompanied 
by  less  constitutional  disturbance  than  are  carbuncles. 

What  anesthetic  would  you  select  for  an  operation 
about  the  mouth? 

Chloroform,   unless  contra-indicated. 

What  is  an  adenoma? 

An  adenoma  is  a  tumor,  the  minute  structure  of  which  re- 
sembles that  of  a  gland.  Unlike  normal  glands,  these  tumors 
have  no  secretory  ducts  and  no  physiologic  function. 

Through  what  channels  is  carcinoma  disseminated? 

Through  the  lymphatic  channels. 

Describe  a  dissecting  aneurysm. 

A  dissecting  aneurysm  is  one  in  which  the  blood  breaks 
through  an  atheromatous  ulcer  in  the  intima  and  burrows  its 
way  through  the  substance  of  the  media;  the  sac  of  the  aneu- 
TA'sin  is  formed  within  the  wall  of  the  vessel. 


602  SURGERY. 

What  are  the  varieties  of  hydrocele? 

Hydroceles  of  the  cord :  1.  Diffuse ;  2.  Encysted. 

Hydoceles  of  the  testicle:  1.  Vagiual ;  2.  Congenital;  3. 
Infantile;  4.  Hydrocele  of  the  funicular  process  (lower  por- 
tion) ;  5.  Encysted;  6.  Hydrocele  of  a  hernial  sac. 

Enumerate  the  diagnostic  points  in  intussusception. 

Colicky  abdominal  pain,  vomiting,  tenesmus,  the  passage 
of  blood-stained  mucus  or  pure  blood,  and  the  presence  of  a 
sausage-shaped  tumor,  which  usually  is  situated  in  the  line 
of  the  colon,  an  absence  of  resistance  being  observed  in  the 
iliac  fossa.  In  advanced  cases  rectal  examination  may  reveal 
the  presence  of  the  intussusceptum.  Acute  intussusception 
is  more  common  in  early  childhood;  chronic  intussusception 
is  more  frequently  observed  in  adults. 

What  structures  are  divided  in  the  operation  for  stran= 
gulated  femoral  hernia? 

Skin,  superficial  layer  of  superficial  fascia,  cribriform  fas- 
cia, femoral  sheath,  septum  crurale,  subserous  areolar  tissue, 
parietal  peritoneum,  and  the  seat  of  constriction,  which  is 
practically  always  the  lunated  edge  of  Gimbernat's  ligament. 
The  superficial  external  pudic  artery  is  always  cut  and  the 
superficial  epigastric  is  usually  divided. 

With  what  conditions  may  aneurysm  be  confounded? 

Abscesses,  tumors  and  cysts  which  are  situated  near  a  blood- 
vessel, and  pulsating  tumors  of  bone. 

Where  is  the  swelling  and  fluctuation  most  prominent 
in  synovitis  of  the  ankle  joint? 

At  both  sides  of  the  tendo  Achillis  and  in  front  of  both 
malleoli  (between  the  external  malleolus  and  the  extensor 
communis  digitorum  tendons  and  between  the  intenial  mal- 
leolus and  the  tibialis  anticus  tendon). 

Give  a  classification,  either  original  or  from  competent 
authority,  of  burns. 

Dupuytren's  classification  is  the  best.    He  divided  all  burns 


SURGERY.  603 

into  six  classes  or  degrees:  1.  Superficial  burns  followed  by 
redness  and  desquamation  of  the  epidermis;  2.  Bums  fol- 
lowed by  the  formation  of  vesicles  or  bullae;  3.  Burns  de- 
stroying the  cuticle  and  a  portion  of  the  true  skin;  4.  Bums 
extending  into  the  subcutaneous  areolar  tissue;  5.  Burns 
involving  deeper  structures,  such  as  muscles  and  tendons ;  6. 
Burns  involving  all  of  the  constituents  of  the  part. 

Define  an  acute  and  a  chronic  abscess. 

An  acute  abscess  is  one  which  develops  with  all  the  signs 
and  symptoms  of  inflammation.     It  contains  pus. 

A  chronic  abscess  is  one  which  is  formed  without  the  signs 
and  symptoms  of  acute  inflammation.  As  a  rule  it  is 
tubercular,  and  does  not  contain  true  pus  unless  a  mixed 
infection  has  occurred. 

Mention  the  causes  of  dislocation.  Give  the  cardinal 
symptoms  of  dislocation. 

Predisposing  causes :  1.  The  anatomic  peculiarities  of  the 
joint;  2.  The  situation  of  the  joint;  3.  Active  adult  life;  4. 
The  male  sex. 

Exciting  causes:  1.  External  violence  (direct  or  indirect)  ; 
2.  Muscular  action. 

Symptoms:  1.  An  alteration  in  the  shape  of  the  joint,  the 
displaced  articular  extremity  being  frequently  felt  in  an 
abnormal  position ;  2.  An  alteration  in  the  length  of  the 
affected  member  (shortening  or  elongation)  ;  3.  More  or  less 
immobility  of  the  affected  joint;  4.  An  alteration  in  the  direc- 
tion of  the  axis  of  the  extremity. 

Dislocations,  like  fractures,  are  usually  accompanied  by 
pain,  swelling  and  ecchymosis. 

How  are  amputations  classified  in  re8:ard  to  time  of 
operating?    What  period  is  most  favorable  for  operation? 

I'riinary;  the  amputation  is  performed  before  tiie  develop- 
ment of  inflammation. 

Intermediate;  the  amputation  is  performed  during  the  ex- 
istence of  active  inflammation. 


604  SURGERY. 

Secondary ;  the  amputation  is  performed  after  the  subsi- 
dence of  the  inflammatory  phenomena. 

The  primary  period  is  the  one  most  favorable  for  operation. 

Under  what  circumstances  should  an  artery  be  ligated 
in  its  continuity?  What  instruments  are  required  for  the 
operation? 

An  artery  should  be  ligated  in  its  continuity  to  check 
hemorrhage,  to  promote  the  cure  of  an  aneurysm,  to  diminish 
the  rate  of  growth  of  a  tumor,  to  reduce  the  blood  supply  of 
an  organ,  and  as  a  preliminary  step  to  the  removal  of  some 
vascular  structure  (such  as  the  tongue).  The  instruments  re- 
quired are  a  scalpel,  dissecting  forceps,  retractors,  a  grooved 
director,  several  hemostats,  an  aneurysm  needle,  ligatures, 
needles,  and  sutures. 

What  are  the  causes  of  stricture  of  the  rectum? 

Congenital  malformation,  syphilis,  carcinoma,  dysentery, 
tuberculosis,  gonorrhea,  traumatism  or  operations  involving 
the  greater  portion  of  the  circumference  of  the  bowel,  repeated 
attacks  of  inflamed  hemorrhoids,  chronic  proctitis,  inflamma- 
tory thickening  outside  of  the  gut,  as  in  cases  of  pelvic 
cellulitis  after  labor,  and  tumors  pressing  upon  the  rectum 
and  narrowing  its  lumen. 

Define  nephrorrhaphy,  nephrotomy,  nephrectomy.  Give 
an  indication  for  the  performance  of  each. 

By  nephrorrhaphy  is  meant  the  stitching  of  a  kidney  to  the 
posterior  wall  of  the  abdomen.     Indication,  floating  kidney. 

By  nephrotomy  is  meant  the  cutting  into  kidney.  Indi- 
cation, renal  calculus. 

By  nephrectomy  is  meant  the  excision  of  a  kidney.  Indi- 
cation, a  primary  malignant  renal  growth. 

Name  the  methods  of  inflating  the  tympanum. 

Valsalva's,  Politzer's,  and  by  means  of  the  Eustachian, 
catheter. 


SURGERY.  605 

What  are  the  conditions  which  render  excision  of  the 
lower  jaw  advisable? 

Malignaut  tumors  of  the  mandible,  malignant  tumors  in 
the  adjacent  tissues  involving  the  bone  secondarily,  trau- 
matism, and  necrosis  may  render  excision  advisable. 

What  are  the  complications  of  dislocation  of  the  hip? 

Fracture  of  the  acetabulum  (with  or  without  injury  to  the 
pelvic  viscera),  fracture  of  some  portion  of  the  upper  ex- 
tremity of  the  femur,  rupture  of  the  femoral  artery,  paralysis 
from  compression  or  rupture  of  a  nerve-trunk,  and  extensive 
laceration  of  the  neighboring  soft  parts. 

What  arteries  need  ligating  in  amputation  at  the  middle 
third  of  the  leg?     Describe  your  method  of  ligating. 

The  anterior  tibial,  the  posterior  tibial,  and  the  peroneal. 
The  anterior  tibial  artery  will  be  found  just  above  the  inter- 
osseous membrane  lying  between  the  tibialis  anticus  and  the 
extensor  proprius  hallucis.  The  artery  should  be  freed  from 
the  surrounding  structures  and  ligated  separately  or  to- 
gether with  the  two  venae  comites,  care  being  taken  not  to 
include  the  anterior  tibial  nerve.  If  the  artery  cannot  be 
reached  owing  to  excessive  retraction,  the  patient  should  be 
turned  on  his  face,  when  the  weight  of  the  stump  will  extend 
the  limb  and  make  the  vessel  much  easier  of  access.  The  pos- 
terior tibial  will  be  found  behind  the  tibia  lying  upon  the 
flexor  longus  digitorum  or  between  it  and  the  tibialis  pos- 
ticus. It  should  be  freed  from  surrounding  structures  and 
ligated  separately  or  together  with  its  two  venae  comites ; 
care  must  be  taken  not  to  include  the  posterior  tibial  nerve. 
The  peroneal  artery  will  be  found  behind  the  fibula  between 
the  tibialis  posticfus  and  flexor  longus  hallucis  or  surrounded 
by  the  fibres  of  the  flexor  longus  hallucis.  It  should  be  freed 
from  surroundinfir  structures  and  ligated  separately  or  to- 
gether with  its  two  venae  comites.  Both  the  posterior  tibial 
and  the  peroneal  arteries  will  be  found  anterior  to  the  deep 
transverse  fascia  of  the  leg.     After  the.se  three  arteries  have 


606  SURGERY. 

been  secured,  the  tourniquet  should  be  loosened  and  any  other 
bleeding  point  seized  and  tied. 

Where  may  a  ligature  be  applied  for  aneurysm  of  the 
popliteal  artery? 

Preferably  at  the  apex  of  Scarpa's  triangle  or  in  Hunter's 
canal.  It  may  also  be  applied  in  the  upper  portion  of  the 
popliteal  space,  just  after  the  passage  of  the  artery  through 
the  opening  in  the  adductor  magnus. 

What  are  the  indications  for  litholapaxy  (rapid  litho= 
trity)  as  compared  with  (a)  lateral  perineal  lithotomy; 
(b)  median  perineal  lithotomy;  (c)  suprapubic  lithotomy? 

Unless  some  contra-indication  exists  litholapaxy  is  the 
operation  par  excellence.  The  contra-indications  are :  1, 
Encysted  calculus  (absolute  contra-indication)  ;  2.  A  stone 
larger  than  II/2  inches  in  diameter,  though  many  surgeons 
will  crush  much  larger  stones ;  3.  Stones  consisting  of  calcium 
oxalate  are  so  hard  that  the  crushing  operation  is  difficult 
and  sometimes  impossible ;  4.  Excessive  irritability  of  the 
urethra;  5.  Uirethral  stricture  of  old  standing  not  capable  of 
dilatation  or  the  existence  of  false  passages;  6.  Cystitis;  7. 
Enlarged  prostate;  8.  Sacculated  or  contracted  bladder  (hold- 
ing less  than  six  ounces)  ;  9.  Extensive  renal  disease  (unless 
there  is  no  doubt  that  the  operation  may  be  quickly  per- 
formed). 

Lateral  perineal  lithotomy  is  indicated:  1.  "Where  cystitis 
and  great  irritability  of  the  bladder  are  present;  2.  In  phos- 
phatic  concretions;  3.  If  the  bladder  is  contracted. 

Mediam  perineal  lithotomy  is  rarely  performed,  as  the  open- 
ing is  much  smaller  than  in  the  lateral  operation.  The 
advantages  claimed  for  it  are  the  small  amount  of  hemor- 
rhage and  the  lessened  danger  of  urinary  infiltration  and 
injury  to  the  ejaculatory  ducts. 

Suprapubic  lithotomy  is  to  be  performed :  1.  When  the 
stone  is  too  large  to  crush;  2.  If  the  stone  is  encysted;  3.  If 
old  strictures  or  an  enlarged  prostate  is  present;  4.  When  the 


SURGERY.  607 

patient  cannot  assume  the  lithotomy  position  (ankylosis  of 
left  hip,  rachitic  contraction  of  pelvis,  presence  of  a  tumor)  ; 
5.  When  the  crushing  operation  is  not  deemed  advisable  in 
young  boys. 

The  indications  for  the  suprapubic  operation  have  been 
greatly  extended  in  recent  years  at  the  expense  of  the  perineal 
method.  The  only  two  absolute  contra-indications  to  the 
procedure  are  severe  septic  cystitis  and  contraction  of  the 
bladder. 

What  fractures  do  not  present  mobility?  Under  what 
circumstances  is  crepitus  absent? 

Impacted  fractures  and  incomplete  fractures  do  not  present 
preternatural  mobility. 

Crepitus  is  absent  in  impacted  fractures,  in  incomplete 
fractures,  where  there  is  great  separation  or  over-riding  of 
the  fragments,  and  v^ere  portions  of  muscle,  tendon,  or  peri- 
osteum are  between  the  fragments. 

What  symptoms  follow  division  of  the  radial  nerve? 

Anesthesia  over  the  radial  side  of  the  dorsal  surface  of  the 
wrist  and  hand  and  over  the  dorsal  surface  of  the  thumb, 
index,  middle,  and  radial  half  of  ring  fingers,  excepting  over 
the  terminal  phalanges. 

What  conditions  of  the  kidneys  require  nephrectomy? 

Any  of  the  following  conditions  may  require  nephrectomy : 
Carcinoma,  sarcoma,  tuberculosis,  calculous  pyonephrosis, 
hydronephrosis,  traumatic  lesions  (particularly  if  compli- 
cated by  laceration  of  the  peritoneum),  and  some  cases  of 
ruptured  ureter. 

How  may  a  quart  of  normal  salt  solution  be  prepared 
at  the  patient's  home? 

By  dissolving  two  teaspoonfuls  of  salt  in  a  (juart  of  water. 
The  solution  may  be  sterilized  by  boiling.  The  percentage  of 
salt  is  not  accurate,  but  it  is  near  enough  for  practical  pur- 
poses. 


'608  SURGERY. 

What  are  the  principal  affections  of  synovial  bursae? 

Acute  simple  bursitis,  acute  suppurative  bursitis,  chronic 
fibroid  bursitis,  chronic  bursitis  with  effusion  (house-maid's 
knee),  chronic  tuberculous  bursitis,  syphilitic  and  gouty  de- 
posits. 

What  muscles  are  divided  in  the  operation  for  (a)  di= 
verging  strabismus,    (b)    converging  strabismus? 

fa)  The  external  rectus,  (b)  The  internal  rectus. 

How  would  you  reduce  a  dislocation  of  the  inferior 
maxillary  bone? 

It  is  only  necessary  to  depress  the  condyle  below  the  level 
of  the  eminentia  articularis,  when  the  masseter,  temporal  and 
internal  pterygoid  muscles  will  readily  draw  it  back  into  the 
glenoid  cavity.  The  patient  is  to  be  seated,  the  surgeon 
stands  in  front  of  the  patient  and  presses  down  upon  the 
molar  teeth  with  his  two  thumbs,  which  are  guarded  by  a 
towel.  This  pressure  is  continued  in  a  downward  and  back- 
ward direction  until  the  condyle  clears  the  eminentia  articu- 
laris, when  the  chin  is  to  be  raised  by  the  fingers.  The  jaw 
should  be  kept  at  rest  for  four  or  five  days  by  a  Barton 
bandage. 

Name  the  varieties  of  shoulder=joint  dislocations. 

Anterior  (subcoracoid,  intracoracoid,  subclavicular),  down- 
ward (subglenoid,  erecta),  posterior  (subacromial,  subspi- 
nous), and  upward  (.supraglenoid). 

What  are  the  possible  mechanical  obstructions  in  the 
reduction  of  fractures? 

Muscular  spasm,  the  interposition  of  muscle  or  periosteum 
between  the  ends  of  the  fragments,  impaction  of  the  frag- 
ments, perforation  of  the  skin  by  one  of  the  fragments,  and 
effusion  into  a  joint  (in  fracture  of  patella  or  of  olecranon). 

What  are  the  sources  of  wound  infection? 

A  wound  may  be  infected  by  the  foreign  body  making  the 
wound,  by  any  foreign  substance  or  fluid  coming  in  contact 


SURGERY.  609 

with  the  wound,  by  the  blood,  by  the  skin  of  the  patient,  by 
the  hands  of  the  surgeon  and  assistants,  and  by  instruments, 
ligatures,  sutures  or  dressings.  Aerial  infection  is  very  rare, 
though  possible. 

Relate  the  difference  between  a  sinus  and  a  fistula. 

A  sinus  is  an  abnormal  canal  leading  from  the  skin  or 
mucous  membrane  to  an  abnormal  cavity.  It  has  but  one 
opening. 

A  fistula  is  an  abnormal  communication  between  the  skin 
or  mucous  membrane  and  a  normal  cavity.  It  has  two  open- 
ings. 

Define  pyemia  and  give  its  symptoms. 

By  pyemia  is  meant  a  general  infection  of  the  blood  with 
pyogenic  organisms.  It  is  septicemia  plus  metastatic  ab- 
scesses. 

Symptoms :  Repeated  rigors  with  a  markedly  remittent 
temperature,  exhausting  diaphoresis,  hyperesthesia  of  the 
skin,  suppuration  in  joints  not  usually  involved  in  other 
febrile  affections  (sterno-clavicular,  sacro-iliac) .  and  diar- 
rhea. If  there  is  an  open  wound  it  will  become  dry  and 
glazed.  Physicial  examination  will  reveal  the  signs  of  pulmo- 
nary congestion  or  pneumonia,  metastatic  abscesses  may  be 
detected  in  various  portions  of  the  body,  and  examinations 
of  the  blood  show  a  leukocytosis.  The  mind  is  usually  clear. 
Toward  the  termination  of  the  affection  the  patient  may  fall 
into  the  typhoid  state. 

What  are  the  indications  for  castration? 

Castration  may  be  performed  for  malposition,  for  tuber- 
culous disease,  for  old  standing  hematoceles,  for  simple  or 
malignant  tumors,  after  some  injuries,  and  for  chronic  en- 
largement of  the  prostate. 

Give  the  causes  and  sequelae  of  suppurative  middle  ear 
disease. 

Causes:   Inflammations  in  the  naso-pharynx  and  infected 
wounds  of  the  membrana  tympani. 
39 


610  SURGERY. 

Sequelae :  These  may  be  divided  into  the  extracranial,  cra- 
nial and  intracranial. 

Extracranial :  Eczema  of  meatus,  furuncles  of  meatus,  sub- 
periosteal abscess  and  necrosis  of  tympanic  plate. 

Cranial :  Necrosis  of  ossicles,  caries  or  necrosis  of  temporal 
bone,  polypi,  facial  paralysis  and  mastoiditis. 

Intracranial :  Extradural  abscess,  localized  or  diffused  men- 
ingitis, thrombosis  of  the  lateral  sinus,  and  cerebral  or  cere- 
bellar abscess.  Remember  that  50  per  cent,  of  all  cases  of 
brain  abscess  are  due  to  this  cause. 

State  the  causes  of  exophthalmos. 

Paralysis  of  the  third  cranial  nerve,  intra-orbital  aneurysm, 
intra-orbital  tumors,  thrombosis  of  cavernous  sinus,  fracture 
of  anterior  fossa  with  laceration  of  cavernous  sinus,  em- 
pyema of  the  antrum,  tumors  of  the  antrum,  and  exoph- 
thalmic goitre. 

What  are  gliomata  and  where  are  they  found? 

Gliomata  are  tumors  composed  of  neuroglia.  They  occur  in 
the  brain,  spinal  cord,  and  rarely  in  the  cranial  nerves.  The 
so-called  glioma  of  the  eye-ball  is  really  a  sarcoma. 

Mention  obstacles  to  reduction  of  dislocations. 

Muscular  resistance,  anatomical  peculiarities  of  the  joint, 
the  interposition  of  shreds  of  the  capsular  ligament,  fracture 
of  the  bone  involved,  and  the  presence  of  adhesions  (old  dis- 
locations). 

Define  torticollis.  Give  the  differential  diagnosis  of 
torticollis  and  cervical  caries. 

Torticollis  or  wry-neck  is  a  deformity  due  to  contraction  of 
certain  muscles  on  one  side  of  the  neck.  The  sterno-mastoid 
is  first  affected,  but  the  trapezius,  the  splenius,  the  platysma,^ 
and  even  the  cervical  fascia  may  be  involved. 

In  cervical  caries  motion  in  all  directions  is  restricted,  and 
pain  is  elicited  by  pressing  upon  the  cervical  vertebrae;  in 
torticollis  motion  is  restricted  in  but  one  direction,  that  in 
which  the  muscle  involved  is  put  upon  the  stretch. 


SURGERY.  611 

Describe  hypospadias,  epispadias,  phimosis,  and  para= 
phimosis. 

Hypospadias  is  a  malformation  in  which  the  urethra  opens 
upon  the  under  surface  of  the  penis. 

Epispadias  is  a  malformation  in  which  the  urethra  is  par- 
tially or  wholly  exposed  on  the  upper  surface  of  the  penis. 

Phimosis  is  that  condition  in  which  the  prepuce  is  elon- 
gated, and  in  which  the  preputial  orifice  is  so  narrow  that  it 
can  not  be  retracted  behind  the  corona  glandis. 

By  paraphimosis  is  meant  a  strangulation  of  the  glans  penis 
by  a  prepuce  which  has  been  forcibly  retracted  and  cannot  be 
replaced. 

What  is  genu  valgum?  State  how  genu  valgum  should 
be  treated. 

Genu  valgum  or  knock-knee  is  a  deformity  in  which  there 
is  an  abduction  of  the  legs  from  the  median  line,  together 
with  a  certain  amount  of  external  rotation.  The  two  inner 
condyles  may  be  brought  into  apposition,  while  the  two  inter- 
nal malleoli  are  separated.  Young  children  (up  to  the  fifth 
or  sixth  year)  in  whom  the  deformity  is  not  great  may  be 
treated  by  mechanical  appliances.  If  due  to  rickets  appro- 
priate constitutional  treatment  must  be  observed.  When  the 
deformity  is  great  and  the  age  of  the  patient  precludes  the 
hope  of  a  cure  by  mechanical  means,  osteotomy  is  indicated. 
The  best  method  of  performing  osteotomy  is  that  of  Macewen. 

What  are  the  symptoms  when  the  ulnar  nerve  has  been 
divided  on  a  level  with  the  pisiform  bone? 

Loss  of  adduction  and  abduction  of  the  fingers,  flexion  of 
the  last  two  phalanges  of  each  finger,  and  hyper-extension  at 
the  metacarpophalangeal  joint  ("claw-hand").  The  inter- 
osseous spaces  become  very  marked  from  the  atrophy  of  the 
muscles  involved  (the  two  inner  lumbricales  and  all  of  the 
interossei).  There  is  also  a  paralysis  of  the  short  muscles 
of  the  little  finger,  of  some  of  the  thumb  muscles  (adductor 
transversus.  adductor  n>)liquus.  and  part  of  flexor  brevis  pol- 


612  SURGERY. 

licis),  and  of  the  palmaris  brevis.  There  is  anesthesia  of  the 
ulnar  side  of  the  dorsum  and  palm  of  the  hand,  and  of  both 
dorsal  and  palmar  surfaces  of  the  little  and  ulnar  side  of  the 
ring  fingers. 

What  tissues  are  divided  in  the  operation  for  oblique 
inguinal  hernia? 

Skin,  superficial  fascia,  intercolumnar  fascia,  cremaster 
muscle,  infundibuliform  fascia,  subserous  areolar  tissue,  and 
parietal  peritoneum.  The  superficial  epigastric  and  the 
superficial  external  pudic  arteries  are  always  divided. 

What  are  the  indications  for  the  operation  of  gastros= 
tomy? 

Malignant  disease  of  the  esophagus  and  stricture  or  stenosis 
of  the  esophagus  from  any  cause,  when  the  patient  is  unable 
to  take  sufficient  nourishment. 

What  is  the  differential  diagnosis  between  septicemia 
and  pyemia? 

Septicemia  occurs  before  the  advent  of  suppuration;  re- 
peated rigoi's  and  metastatic  abscesses  are  absent,  and  the 
patient  is  delirious. 

Pyemia  occurs  after  the  advent  of  suppuration;  repeated 
rigors  and  metastatic  abscesses  are  present,  and  delirium,  if 
present  at  all,  is  apt  to  be  nocturnal. 

A  differential  diagnosis  is  frequently  impossible,  but  the- 
oretically the  points  given  above  are  those  to  be  expected. 

Give  the  differential  diagnosis  between  sacro°iliac  dis= 
ease  and  morbus  coxarius. 

In  sacro-iliac  disease  pressure  upon  the  crests  of  the  ilia 
causes  pain;  if  the  pelvis  be  supported,  the  thigh  may  be 
moved  in  all  directions  without  much  discomfort;  apparent 
or  real  shortening  of  the  lower  extremity  is  never  present. 

In  morbus  coxarius  pressure  upon  the  crests  of  the  ilia 
produces  no  pain;  motion  of  the  thigh  is  accompanied  by 
pain;  apparent  or  real  shortening  of  the  lower  extremity  is 
always  present  at  some  stage  of  the  affection. 


SURGERY.  613 

What  are  the  principal  affections  of  muscles? 

Contusion,  sprain,  rupture  of  sheath,  rupture  of  muscle  or 
tendon,  displacement  of  tendon,  myositis  (traumatic,  rheu- 
matic, acute  suppurative,  tubercular,  syphilitic,  parasitic,  and 
myositis  ossificans),  primary  tumors  (angioma,  fibroma, 
chondroma,  myxoma,  and  sarcoma),  and  secondary  tumors 
(carcinoma  and  sarcoma). 

Give  the  indications  and  methods  for  ligature  of  the 
common  carotid  artery. 

The  common  carotid  artery  is  tied  for  aneurysm,  for  wounds 
of  the  internal  or  external  carotid  artery  or  their  branches, 
to  check  malignant  growths,  and  as  a  preparatory  procedure 
to  the  removal  of  tumors. 

Ligation  in  superior  carotid  triangle.  The  patient  should 
be  on  his  back  with  his  shoulder  elevated,  the  head  thrown 
back,  and  the  face  turned  slightly  to  the  opposite  side.  After 
all  aseptic  precautions  have  been  carried  out  an  incision  three 
inches  in  length  is  made  in  the  line  of  the  artery  (from  the 
sterno-clavicular  articulation  to  a  point  midway  between  the 
angle  of  the  jaw  and  the  mastoid  process),  the  center  of  the 
incision  being  opposite  the  cricoid  cartilage.  The  skin,  super- 
ficial fascia,  platysma  myoides,  and  superficial  layer  of  the 
deep  fascia  are  to  be  divided,  the  sterno-mastoid  muscle  drawn 
outward,  the  tendon  of  the  omo-hyoid  drawn  do^vnward,  and 
the  pulsations  of  the  artery  sought  for  beneath  the  sterno- 
mastoid.  The  sheath  is  now  opened  upon  the  inner  side,  the 
aneurysm  needle  is  passed  from  without  inward,  threaded, 
and  withdrawn. 

Ligation  in  inferior  carotid  triangle.  Patient  in  same 
[position  as  before.  The  incision  is  made  in  the  line  of  the 
artery  from  the  level  of  the  cricoid  cartilage  to  the  sterno- 
clavicular articulation,  and  divides  skin,  superficial  fascia, 
platysma,  and  superficial  vessels  and  nerves.  The  superficial 
layer  of  the  deep  cervical  fascia  is  then  divided,  the  sterno- 
mastoid  muscle  drawn  outward,  and  the  stemo-hyoid  and 
sterno-thyroid  muscles  drawn  inward.     The  sheath  is  opened 


614  SURGERY. 

upon  the  inner  side,  and  the  aneurysm  needle  passed  from 
without  inward. 

What  operations  are  performed  for  intractable  neural= 
gia  of  the  fifth  nerve? 

Neurotomy,  nerve-stretching,  removal  of  Meckel's  ganglion, 
neurectomy,  and  removal  of  the  Gasserian  ganglion.  Accord- 
ing to  the  symptoms,  one  or  more  of  the  following  nerves  may 
be  resected:  Supra-orbital,  supra-trochlear,  infra-orbital,  in- 
ferior maxillary  division  of  the  fifth,  lingual,  inferior  dental, 
and  mental. 

State  the  most  common  seat  of  fracture  of  the  clavicle 
and  describe  a  method  of  treatment. 

At  the  outer  end  of  the  middle  third  of  the  bone. 

Sayre's  method.  Three  strips  of  adhesive  plaster  three  and 
one-half  inches  wide  and  long  enough  to  encircle  the  chest  and 
arm  are  required.  A  loop  is  made  in  the  end  of  the  first  strip ; 
this  loop  is  secured  by  stitches  and  made  to  encircle  the  arm 
close  to  the  axilla,  the  non-adhesive  surface  of  the  plaster 
being  next  to  the  skin.  The  shouder  is  then  drawn  backwards 
and  the  adhesive  strip  carried  around  the  chest  from  behind 
forward  (adhesive  surface  next  to  skin),  passing  over  the 
front  of  the  chest,  under  the  axilla,  and  finally  attached  to  the 
part  crossing  the  back.  The  elbow  of  the  injured  side  is  now 
brought  forward  and  the  hand  placed  upon  the  sound  shoul- 
der. As  the  loop  of  the  first  strip  acts  as  a  fulcrum,  the  shoul- 
der and  outer  extremity  of  the  clavicle  are  carried  backward. 
With  the  arm  in  this  position  the  end  of  the  second  strip  is 
fixed  to  the  sound  shoulder,  and  the  strip  is  then  brought 
downwards  across  the  back  to  the  elbow  of  the  injured  side 
(a  hole  being  cut  in  the  plaster  to  accommodate  the  olecra- 
non) upwards  across  the  front  of 'the  chest  and  forearm,  and 
fastened  to  the  other  end  over  the  top  of  the  sound  shoulder. 
This  strip  holds  the  shoulder  back  and  keeps  it  raised.  The 
third  strip  is  passed  horizontally  about  the  chest  and  forearm 
to  hold  the  extremity  against  the  body.     A  towel  should  be 


SURGERY.  615 

placed  in  the  axilla,  and  all  contiguous  cutaneous  surfaces 
should  be  separated  by  pieces  of  lint.  This  position  is  to  be 
maintained  until  union  occurs  (about  three  or  four  weeks). 
and  the  movements  of  the  arm  should  be  restricted  for  a  week 
or  so  longer. 

Give  the  causes  of  atrophy. 

Causes :  1.  Diminished  functional  activity ;  2.  Defective 
nutrition;  3.  Pressure;  4.  Nervous  influence  (neuropathic 
atrophy)  ;  5.  Senility. 

What  symptoms  follow  division  of  the  facial  nerve? 

Paralysis  of  the  same  side  of  the  face  without  implication 
of  palate  or  uvula  (it  is  presumed  that  the  nerve  has  been 
divided  after  its  exit  from  the  skull).  The  paralyzed  side  of 
the  face  is  immobile,  devoid  of  expression,  and  the  natural 
folds  and  wrinkles  are  obscured.  The  eye-lids  cannot  be 
completely  closed,  the  eye-ball  rolling  upward  and  outward 
when  forcible  closure  is  attempted.  Epiphora  is  present 
from  the  drooping  of  the  lower  lid.  The  lips  cannot  be 
firmly  closed,  and  whistling  is  impossible.  If  attempts  are 
made  to  move  the  face  (to  show  the  teeth  or  laugh)  marked 
.asymmetry  is  produced,  the  face  being  drawn  toward  the 
non-paralyzed  side.  Owing  to  the  paralysis  of  the  bucci- 
nator, food  collects  between  the  teeth  and  the  cheek. 

What  method  of  treatment  affords  the  most  prompt 
relief  in  paronychia? 

Evacuation  of  the  pus  or  inflammatory  exudate  by  means 
of  an  incision,  the  introduction  of  a  small  strip  of  iodoform 
L^auze  for  drainage,  and  the  application  of  a  moist  antiseptic 
dressing. 

Describe  the  operation  for  ligature  of  the  subclavian 
artery  in  its  second  part. 

Tlie  patient  should  be  in  the  dorsal  position,  with  a  cushion 
beneath  the  shoulders,  face  turned  to  the  opposite  side,  and 
the  shonlder  depressed.     After  all   a.septic  precautions  have 


616  SURGERY. 

been  carried  out,  the  skin  should  be  drawn  down  over  the 
clavicle,  and  an  incision  made  over  the  bone  extending  from 
the  middle  of  the  clavicle  almost  to  the  sterno-clavicular 
articulation.  The  skin  is  then  allowed  to  retract,  and  the 
wound  will  be  half  an  inch  above  the  clavicle.  This  incision 
divides  the  skin,  superficial  fascia,  platysma  myoides,  and  the 
superficial  layer  of  the  deep  cervical  fascia.  The  clavicular 
head  of  the  sterno-mastoid  muscle  should  then  be  divided, 
and  any  veins  overlying  the  prevertebral  fascia  covering  the 
scalenus  antieus  ligated.  The  prevertebral  fascia  is  then 
incised,  the  phrenic  nerve  drawn  inward,  and  the  outer  two- 
thirds  of  the  anterior  scalenus  muscle  divided  close  to  its 
attachment  to  the  first  rib.  Care  must  be  taken  not  to  wound 
the  anterior  jugular,  external  jugular,  internal  jugular  or 
subclavian  veins,  the  phrenic  nerve  or  the  pleura.  The  needle 
is  passed  from  before  backward  and  from  below  upward. 

What  are  the  varieties  of  ankylosis? 

Incomplete  or  fibrous  and  complete  or  bony.  Ankylosis  is 
also  spoken  of  as  being  either  true  (involvement  of  articular 
structures)  or  false  (result  of  extra-articular  lesions). 

When  is  operative  interference  advisable  in  the  treat- 
ment of  malignant  tumors? 

Operative  interference  is  advisable  when  the  tumor  can  be 
thoroughly  removed,  when  the  operation  will  diminish  pain 
or  make  the  patient  more  comfortable,  and  when  it  will 
lengthen  the  life  of  the  patient. 

Describe  the  several  varieties  of  clubfoot. 

Talipes  equinus.  The  heel  is  drawn  up  and  the  patient 
walks  upon  his  toes. 

Talipes  calcaneus.  The  toes  are  raised  from  the  ground 
and  the  patient  walks  upon  his  heel. 

Talipes  varus.  The  anterior  half  of  the  foot  is  adducted, 
the  inner  side  of  the  foot  is  raised,  and  the  patient  walks  upon 
the  outer  side. 

Talipes  valgus.     The  anterior  half  of  the  foot  is  abducted 


SURGERY.  617 

and  everted,  the  patient  resting  upon  the  inner  side  of  the 
foot.  Various  combinations  of  these  forms  are  indicated  as 
follows :  Talipes  equino-varus,  talipes  equino-valgus.  talipes 
calcaneo-varus,  and  talipes  ealeaneo-valgus. 

Name  the  most  common  varieties  of  fistula. 

Fistula  in  ano  (complete,  blind  internal,  blind  external), 
vesico-vaginal,  urethro-vaginal.  recto-vaginal,  urinary,  sali- 
vary, biliary,  and  intestinal. 

What  is  lupus? 

Lupus  vulgaris  is  a  chronic  intlammatory  disease  of  the 
skin  and  mucous  membranes  due  to  the  tubercle  bacillus,  and 
characterized  by  the  formation  of  nodules  of  granulation  tis- 
sue. These  nodules  usually  ulcerate  (lupus  exedens).  but 
such  is  not  always  the  case  ( lupus  non-exedens) . 

What  are  the  indications  for  enucleation  of  the  globe? 

Malignant  disease,  either  primary  or  extending  from  adja- 
cent tissues,  rupture  and  collapse  of  eye-ball,  a  large  irregular 
foreign  body  in  the  eye  not  capable  of  being  successfully 
removed,  a  large  wound  in  the  dangerous  region  in  which 
little  hope  of  obtaining  useful  sight  remains,  a  small  wound 
in  the  dangerous  region  with  commencing  irido-cyclitis,  a  small 
foreign  body  not  removable  by  the  electro-magnet  and  causing 
inflammation  and  shrinking,  a  wound  in  the  dangerous  region 
complicated  with  traumatic  cataract,  a  corneal  wound  in 
which  severe  iritis  and  panophthalmitis  develop  in  spite  of 
treatment,  and  any  case  in  which  sympathetic  ophthalmia  is 
threatened.     (Modified  from  Jacobson.) 

Give  the  symptoms,  diagnosis,  and  treatment  of  phle- 
bitis. 

Symptoms :  The  vessel  aft'ected  becomes  swollen,  hard,  and 
painful.  Localized  enlargements  corresponding  to  the  posi- 
tion of  the  valves  are  observed.  The  overlying  tissues  are 
dusky  and  congested,  and  there  may  be  some  edema  in  the 
area  drained  by  the  vein.     The  part  is  hot  to  the  tou<'h  and 


618  SURGERY. 

the  patient  usually  has  fever.  If  suppuration  occurs  the 
symptoms  are  those  of  a  localized  abscess. 

Diagnosis:  In  lymphangitis  the  redness  is  brighter  and 
more  localized,  enlarged  and  painful  glands  are  present,  there 
is  no  hard  cord-like  vein,  and  the  swelling  is  much  less  marked. 
In  erysipelas  the  redness  is  characterized  by  an  abrupt  raised 
margin,  and  gastric  disturbances  are  frequently  present. 

Treatment :  Absolute  rest  in  bed,  with  elevation  of  the 
affected  extremity  to  promote  the  return  of  venous  blood. 
The  affected  area  is  covered  with  a  mixture  of  equal  parts  of 
extract  of  belladonna  and  glycerine,  and  the  limb  is  swathed 
in  a  thick  layer  of  cotton  and  lightly  bandaged  to  a  splint. 
The  diet  should  be  nutritious  and  non-stimulating.  When 
the  inflammatory  symptoms  have  subsided,  and  the  clot  has 
had  time  to  become  organized  or  absorbed,  massage  should  be 
practiced  to  get  rid  of  the  edema  and  inflammatory  thicken- 
ing.    If  an  abscess  forms  it  should  be  opened  antiseptically. 

In  septic  phlebitis,  if  seen  early,  the  vein  should  be  ex- 
posed, ligated,  the  whole  of  the  infective  clot  turned  out,  the 
vessel  swabbed  out  with  pure  carbolic  acid  or  bichloride  solu- 
tion (1-500),  and  stuffed  with  antiseptic  gauze.  If  the 
deeper  veins  are  infected  and  this  treatment  is  impossible, 
amputation  may  be  demanded,  provided  that  general  infec- 
tion has  not  taken  place. 

Give  the  causes,  symptoms,  and  treatment  of  acute 
vaginitis. 

Causes:  The  presence  of  .irritating  foreign  bodies,  the  use 
of  irritating  injections,  the  contact  of  irritating  secretions, 
the  irritation  of  excessive  coition,  and  infection  with  gonor- 
rhea. 

Symptoms :  Local  heat,  pain,  and  muco-purulent  discharge. 
Inspection  shows  congestion  and  sometimes  excoriations  of 
the  vaginal  mucous  membrane. 

Treatment :  Rest  in  bed,  saline  cathartics,  and  frequent  hot 
hip-baths.  The  vagina  should  be  copiously  douched  twice 
daily  with  borax    (one  dram  to  a  quart  of  water)    or  with 


SURGERY.  619 

liquor  plumbi  subacetatis  (half  a  fluid-ounce  to  a  quart  of 
water).  As  soon  as  the  acute  symptoms  have  subsided  the 
walls  of  the  vagina  should  be  separated  by  a  fold  of  lint 
soaked  in  oxide  of  zinc  cream.  This  lint  should  be  carried 
well  up  into  the  posterior  fornix,  allowed  to  protrude  at  the 
vulva,  and  changed  every  24  hours.  After  the  disease  has 
subsided  the  parts  should  still  be  douched  occasionally  to 
prevent  recurrence. 

In  gonorrheal  vaginitis  the  vagina  should  be  washed  out 
every  two  or  three  hours,  first  with  a  pint  or  two  of  an  alka- 
line solution,  then  with  a  pint  of  plain  water,  and  then  with 
a  pint  of  a  medicated  solution  (acetate  of  lead,  acetate  of 
zinc,  sulphate  of  zinc,  protargol,  alum,  tannin). 

Define  homologous  tumor,  heterologous  tumor. 

A  homologous  tumor  is  a  tumor  consistiiig  of  tissue  iden- 
tical with  that  of  the  part  in  which  it  grows. 

A  heterologous  tumor  is  a  tumor  consisting  of  a  different 
tissue  from  that  of  the  part  in  which  it  grows.  (These  tumors 
are  more  properly  called  heterotopic  tumors.) 

How  are  dislocations  distinguished  from  fractures? 

Dislocations  are  characterized  by  more  or  less  immobility, 
by  the  absence  of  crepitus,  and  by  the  fact  that  the  deformity 
does  not  usually  recur  after  reduction. 

Fractures  are  characterized  by  preternatural  mobility,  by 
the  presence  of  crepitus,  and  by  the  fact  that  the  deformity 
usually  recurs  after  reduction. 

What  is  milium?    Give  the  treatment. 

Milium  is  an  affection  characterized  by  the  appearance  of 
small,  pearly,  non-inflammatory  elevations,  which  result  from 
the  accumulation  of  inspissated  sebum  in  ducts,  the  outlets  of 
which  have  been  occluded. 

Treatment :  The  lesion  should  be  excised,  the  contents  ex- 
pressed, and  the  same  remedies  employed  as  in  seborrhea 
(improvement  of  general  health,  relief  of  constipation,  and 
the  application  of  ointments  of  sulphur,  mercury,  tar,  car- 
bolic acid,  or  resorcin). 


620  SURGERY. 

Describe  an  operation  for  circumcision. 

After  all  aseptic  precautions  have  been  carried  out,  the 
prepuce  is  drawn  forward  and  grasped  by  a  clamp  placed 
just  in  front  of  the  glans.  The  portion  of  the  prepuce  in 
front  of  the  clamp  is  then  cut  off  with  a  sharp  bistoury  and 
the  clamp  removed.  It  will  be  observed  that  the  skin  has  been 
removed,  but  that  the  mucous  surface  of  the  prepuce  still 
covers  the  glans.  One  blade  of  a  pair  of  scissors  is  now  intro- 
duced into  the  preputial  orifice  and  the  mucous  layer  divided 
down  to  its  attachment  to  the  corona.  All  adhesions  between 
the  prepuce  and  glans  must  be  thoroughly  broken  up  and  the 
smegma  removed.  The  entire  mucous  surface  of  the  pre- 
puce is  to  be  trimmed  away  to  within  an  eighth  of  an  inch  of 
its  attachment  to  the  corona.  Special  attention  should  be 
given  to  the  removal  of  sufficient  tissue  from  the  under  side 
of  the  penis  in  order  to  avoid  an  unsightly  projection  in  the 
neighborhood  of  the  frenum.  Hemorrhage  should  now  be 
controlled,  the  edges  of  the  wound  adjusted  by  a  few  fine 
catgut  sutures,  and  the  line  of  incision  covered  by  some  non- 
irritating  antiseptic  dressing. 

Give  the  local  treatment  of  venereal  bubo. 

Syphilitic  bubo  requires  no  local  treatment. 

Gonorrheal  bubo  may  sometimes  be  aborted  by  the  use  of 
pressure  and  iodine.  If  the  gland  suppurates  it  should  be 
incised  under  antiseptic  precautions,  curetted,  and  treated 
like  any  abscess.  If  the  suppuration  is  within  the  gland  and 
limited  by  the  capsule  the  entire  mass  should  be  dissected  out 
and  the  wound  closed  by  primary  suture.  The  latter  treat- 
ment is  the  best  method  of  dealing  with  suppurating  buboes, 
provided  that  it  is  adopted  at  the  proper  time. 

Give  the  palliative  and  the  remedial  treatment  of  hy= 
drocele. 

Palliative  treatment:  Tapping,  the  use  of  the  suspensory, 
and  evaporating  lotions  (when  inflammation  of  the  testicle 
is  present). 


SURGERY.  621 

Remedial  treatment:  Tapping  and  injection  should  never 
be  employed.  The  open  method  of  treatment  is  now  gener- 
ally adopted.  One  of  three  methods  may  be  pursued :  1.  The 
cavity  of  the  tunica  vaginalis  may  be  opened  and  the  tunica 
stitched  to  the  skin.  The  cavity  is  drained,  washed  out  daily, 
and  the  drainage  tube  gradually  shortened.  Instead  of  a 
tube,  the  cavity  may  be  packed  with  iodoform  gauze.  2. 
The  parietal  layer  of  the  tunica  vaginalis  may  be  excised.  3. 
The  operation  known  as  extraserous  transposition  of  the  tes- 
ticle may  be  employed. 

Give  the  differential  diagnosis  of  congenital  talipes 
equino=varus  and  paralytic  talipes  equino=varus. 

In  congenital  talipes  equino-varus  the  affection  exists  from 
birth,  it  is  usually  bilateral,  the  circulation  is  good,  there  is 
but  little  wasting  of  the  muscles,  the  electric  reactions  are  not 
much  impaired,  the  growth  of  bone  is  much  as  usual,  and 
furrows  are  present  in  the  sole. 

In  paralytic  talipes  equino-varus  the  affection  is  not  de- 
veloped until  the  second  or  third  year  (ushered  in  by  convul- 
sions and  fever),  it  is  more  frequently  unilateral,  the  circula- 
tion is  feeble,  the  muscles  show  extreme  wasting,  electrical 
reactions  are  almost  entirely  absent  in  the  paralyzed  muscles, 
the  growth  of  the  bones  is  considerably  diminished,  and  there 
are  no  furrows  in  the  sole  (after  Tubby). 

Describe  an  approved  method  for  the  removal  of  im- 
pacted cerumen. 

The  external  auditoiy  meatus  is  to  be  syringed  with  warm 
water  (105°  F.),  to  which  some  bicarbonate  of  soda  has  been 
added,  and  the  syringing  continued  until  the  canal  has  been 
thoroughly  cleansed.  The  soda  solution  is  then  to  be  washed 
out  with  sterile  water,  the  ear  wiped  dry,  and  a  cotton  plug 
worn  until  bedtime.  If  the  mass  should  prove  obdurate,  a 
little  warm  sweet  oil  may  be  dropped  into  the  meatus  several 
times  during  the  succeeding  24  hours,  and  the  attempt  re- 
newed upon  the  following  day. 


622  SURGERY. 

Define  malignant  pustule  and  give  treatment. 

Malignant  pustule  or  anthrax  carbuncle  is  a  local  lesion 
produced  by  infection  with  the  bacillus  anthracis.  It  differs 
from  ordinary  carbuncle  in  the  following  respects :  Presence 
of  a  central  depressed  blackish  slough,  absence  of  localized 
pain,  absence  of  suppuration  (unless  mixed  infection  is  pres- 
ent), and  the  constitutional  symptoms  are  more  marked. 

Treatment:  Complete  excision  at  the  earliest  possible  mo- 
ment. The  incisions  should  be  carried  wide  of  the  disease, 
and  the  resulting  wound  should  be  carefully  swabbed  over 
with  pure  carbolic  acid  or  with  a  solution  of  zinc  chloride 
(1:8).  The  constitutional  treatment  should  be  of  a  support- 
ing character. 

What  are  the  parietal  effects  of  a  severe  blow  upon  the 
abdomen? 

Swelling,  discoloration,  tenderness,  and  pain.  If  a  vessel 
of  considerable  size  is  lacerated  a  large  extravasation  of  blood 
will  take  place,  which  may  descend  into  the  scrotum.  Rup- 
ture of  one  of  the  muscles  of  the  abdominal  wall  may  occur, 
and  this  is  most  frequently  observed  in  the  rectus.  As  far 
as  the  abdominal  parietes  are  concerned,  contusions  may  re- 
sult in  localized  peritonitis,  abscess,  or  in  ventral  hernia. 

Describe  the  symptoms  of  fracture  of  the  base  of  the 
skull  in  the  middle  fossa. 

Hemorrhage  from  the  external  auditory  meatus,  or  from 
the  nose.  The  blood  may  be  swallowed  and  subsequently 
vomited.  Cerebro-spinal  fluid  may  be  discharged  from  the 
external  auditory  meatus,  and,  when  present,  is  one  of  the 
most  characteristic  signs  of  fracture  in  this  situation.  If 
the  facial  and  auditory  nerves  are  injured  as  they  lie  in  the 
external  auditory  meatus,  there  will  be  signs  of  paralysis  of 
the  muscles  of  expression  and  deafness  upon  the  affected  side. 
In  addition  to  these  local  signs,  symptoms  of  concussion,  of 
compression,  or  of  laceration  of  the  brain  may  be  present. 


SURGERY.  62S 

What  general  methods  obtain  in  plastic  operations? 

Displacement :  Stretching  or  sliding  of  tissues.  1.  Simple 
approximation  after  freshening  the  edge;  2.  Sliding  into 
position  after  the  transference  of  tension  to  adjoining 
localities. 

Interpolation :  The  tissue  is  taken  from  adjacent  regions, 
from  a  limb,  or  from  another  person.  1.  Transferring  a  flap 
with  a  pedicle;  2.  Transplanting  without  a  pedicle  (includ- 
ing skin-grafting). 

Retrenchment :  The  removal  of  redundant  material  causing 
cicatricial  contraction.    (Abbreviated  from  Keen  and  White.) 

What  is  the  treatment  of  diphtheritic  stenosis  of  the 
larynx? 

Intubation  or  tracheotomy.  The  usual  treatment  of  diph- 
theria should  also  be  instituted  or  continued  (injection  of 
diphtheria  antitoxin,  administration  of  whiskey,  hypoder- 
matic injections  of  strychnine,  absolute  rest  in  bed,  nutritious 
fluid  diet).  If  tracheotomy  has  been  performed  the  temper- 
ature of  the  room  should  be  maintained  at  80°  F.,  and  the 
air  kept  moist  with  steam. 

Describe  a  compound  fracture. 

A  compound  fracture  is  one  in  which  the  seat  of  fracture 
communicates  with  the  external  air.  Such  a  fracture  may 
be  compound  through  the  skin  or  through  the  mucous  mem- 
brane.    These  fractures  are  also  called  open  fractures. 

Give  the  etiology,  varieties  and  symptoms  of  erysipelas. 

Etiology:  Infection  with  the  streptococcus  erysipelatis. 

Varieties:  Cutaneous,  cellulo-cutaneous  (phlegmonous), 
and  cellular  (cellulitis). 

Symptoms:  Cutaneous  ei-ysipelas  is  usually  ushered  in  by 
a  chill  and  more  or  less  gastric  disturbance.  Within  24  hours 
a  rash  appears  in  the  neighborhood  of  the  wound.  There  is 
increased  tension  in  the  part  and  a  sensation  of  itching.  The 
rash  is  yellowish-red  in  color,  disappearing  upon  pressure, 
and  has  a  characteristic  elevated  border.     The  area  affected 


624  SURGERY. 

is  well  defined,  and  the  margins  usually  present  an  irregular 
zigzag  outline.  When  the  inflammation  reaches  its  height 
the  glazed  area  is  covered  with  vesicles  or  bullee  filled  with  a 
clear  fluid,  which  soon  becomes  turbid.  The  rash  advances 
more  or  less  rapidly  with  a  continuous  margin  (remaining 
in  one  situation  for  about  four  days),  and  as  it  extends  to 
new  areas  it  fades  in  the  region  first  involved  and  undergoes 
branny  desquamation.  The  neighboring  lymphatic  glands 
are  usually  enlarged  and  painful.  Fever  is  present  as  long 
as  the  rash  persists.  In  severe  cases  the  fever  is  at  first 
sthenic,  the  pulse  full,  and  the  delirium  noisy  and  active,  but 
the  pulse  subsequently  becomes  quick  and  weak,  and  there  is 
low  muttering  delirium  and  great  prostration. 

What  is  shock,  and  how  should  it  be  treated? 

Shock  is  the  immediate  constitutional  efl:ect  of  an  injury. 

Treatment:  In  mild  cases  very  little  is  needed  except  rest 
in  the  recumbent  position  and  the  exhibition  of  some  pungent 
aromatic  to  the  nostrils.  In  more  severe  cases  the  patient 
must  be  put  absolutely  at  rest,  surrounded  by  blankets  and 
hot  water  bottles,  and  all  external  sources  of  irritation  re- 
moved. Over-stimulation  should  be  avoided,  and  in  many 
cases  a  cup  of  hot  beef  tea  may  do  as  much  good  as  a  stronger 
stimulant.  If  the  patient  appears  to  be  in  imminent  danger, 
however,  more  active  measures  must  be  adopted.  The  head 
should  be  kept  low  and  surrounded  with  flannel  cloths  wrung 
out  of  hot  water  and  frequently  renewed.  The  extremities 
should  be  wrapped  in  blankets  and  external  heat  applied, 
care  being  taken  not  to  burn  the  patient.  Ammonia  should 
be  exhibited  to  the  nostrils  and  small  quantities  of  brandy 
given  by  the  mouth.  If  the  patient  cannot  swallow,  the 
brandy  may  be  diluted  and  given  by  the  rectum.  The  rectal 
injection  of  two  or  three  pints  of  warm  normal  saline  solution 
(100°  F.)  is  highly  recommended.  Ether,  digitalis,  atropine, 
or  strychnine  may  be  given  subcutaneously,  the  latter  drugs 
being  particularly  valuable.  If  the  shock  is  combined  with 
loss  of  blood,  a  pint  of  sterile  normal  saline  solution  should 


SURGERY.  625 

be  injected  beneath  the  skin  or  into  a  vein.  If  a  mangled 
limb  seems  to  act  as  a  source  of  depression  it  may  be  proper, 
under  certain  circumstances,  to  amputate  at  once. 

What  are  the  symptoms  and  treatment  of  a  sprain? 

Symptoms :  The  patient  immediately  experiences  severe 
sickening  pain.  Swelling  soon  makes  its  appearance,  due  at 
first  to  extravasation  of  blood  and  subsequently  to  the  effu- 
sion of  inflammatory  products.  The  patient  is  unable  to  bear 
any  weight  upon  the  injured  extremity,  and  motions  of  the 
joint  are  attended  by  exacerbations  of  the  pain. 

Treatment:  Early  and  systematic  massage  is  invaluable  in 
these  injuries.  Ten  or  twenty  minutes  is  usually  enough  for 
the  first  treatment,  and  the  period  can  be  lengthened  upon 
the  following  days.  During  the  intervals  between  the  mas- 
sage of  the  part,  it  should  be  kept  at  rest  upon  a  well-padded 
splint  and  moderate  compression  applied.  The  immediate 
application  of  cold,  followed  by  heat,  is  of  great  advantage 
in  some  cases.  If  the  sprain  is  in  the  ankle  or  wrist,  the 
patient  should  be  encouraged  to  move  his  toes  or  fingers  while 
the  massage  is  being  performed.  The  old  treatment  con- 
sisted in  keeping  the  part  at  rest  until  all  pain  and  swelling 
had  disappeared,  and  then  employing  massage  and  passive 
motion. 

How  and  in  what  part  of  the  inferior  maxillary  bone  is 
fracture  most  liable  to  occur,  and  what  is  the  treatment? 

The  inferior  maxillary  bone  is  usually  fractured  by  direct 
violence. 

The  most  frequent  site  of  fracture  is  at  a  point  just  ante- 
rior to  the  mental  foramen. 

Treatment:  Reduction  of  the  displacement,  the  application 
of  a  Barton  bandage  and  the  maintenance  of  the  oral  cavity 
in  as  aseptic  a  condition  as  possible.  In  some  cases  a  leather 
or  pasteboard  splint  may  be  applied  over  the  point  of  the 
chin.  If  there  is  a  great  displacement  a  TTammond  splint 
may  be  placed  about  the  teeth  or,  if  these  are  defective, 
40 


626  SURGERY. 

Kingsley's  apparatus  may  be  employed.  Some  few  cases  may 
require  wiring  of  the  fragments.  The  parts  are  to  be  kept 
at  rest  for  about  three  weeks,  the  patient  being  restricted  to 
a  fluid  diet. 

Describe  enucleation  of  the  eye=ball. 

Bonnet's  method:  All  aseptic  precautions  having  been  car- 
ried out,  the  conjunctiva  near  the  cornea  is  grasped  by  for- 
ceps and  divided  with  scissors  entirely  around  and  close  to 
the  corneal  margin.  The  conjunctiva  is  loosened  up  from 
the  eye-ball  and  the  dissection  carried  well  back  in  every 
direction.  The  recti  muscles  are  now  caught  up  separately 
by  a  strabismus  hook  and  their  tendons  divided  close  to  the 
ball.  After  the  orbital  tissues  have  been  well  dissected  away 
from  the  ball  the  enucleation  scissors  are  passed  back  in  the 
orbit  until  they  touch  the  optic  nerve,  when  their  blades  are 
opened  and  the  nerve  divided  as  far  back  as  possible.  The 
oblique  muscles  and  other  remaining  tissues  are  now  quickly 
severed,  the  hemorrhage  is  checked  by  hot  water  or  torsion, 
and  the  orbit  flooded  with  a  hot  bichloride  solution  (1:5000). 

A  drainage  tube  is  then  inserted  into  the  cavity  and  an 
antiseptic  dressing  applied. 

How  is  resection  of  the  spinal  accessory  nerve  effected? 
What  are  the  reasons  for  this  operation? 

After  all  aseptic  precautions  have  been  observed,  an  inci- 
sion is  made  along  the  anterior  border  of  the  sterno-mastoid 
muscle,  extending  from  the  mastoid  process  to  the  comu  of 
the  hyoid  bone  and  avoiding  the  external  jugular  vein.  This 
incision  divides  skin,  superficial  fascia,  platysma,  a  branch 
of  the  auricularis  magnus,  and  the  deep  fascia.  The  sterno- 
mastoid  is  now  drawn  outward,  and  the  nerve  (with  its  accom- 
panying sterno-mastoid  artery)  can  be  felt  just  below  the 
transverse  process  of  the  atlas.  The  nerve  emerges  from, 
beneath  the  posterior  belly  of  the  digastric  and  lies  upon  the 
levator  anguli  scapulae,  beneath  the  prevertebral  fascia.  It 
enters  the  deep  surface  of  the  sterno-mastoid  muscle  midway 


SURGERY.  627 

between  its  two  borders  and  one  inch  below  the  tip  of  the 
mastoid  process.  A  portion  of  the  nerve  is  now  excised,  the 
external  wound  sutured,  and  an  aseptic  dressing  applied. 

The  spinal  accessory  nerve  is  excised  for  spasmodic  torti- 
collis of  central  origin. 

What  are  the  methods  of  reduction  in  sub°coracoid  dis» 
location  of  the  humerus? 

1.  Reduction  by  manipulation  (Kocher's,  Smith's). 

2.  Extension  and  counter-extension. 

3.  Traction  in  an  outward  and  upward  direction. 

How  would  you  arrest  epistaxis? 

If  position,  rest,  cold,  hot  water,  pressure,  and  spraying 
with  peroxide  or  with  a  5  per  cent,  solution  of  antipyrine 
(with  2  per  cent,  cocaine)  are  inefficient,  more  active  meas- 
ures must  be  adopted.  If  the  bleeding  point  can  be  seen  it 
should  be  cauterized  (electricity,  chromic  acid).  When  other 
means  fail  the  anterior  nares  should  be  packed  with  a  strip 
of  sterile  gauze,  the  initial  extremity  of  which  is  carried  well 
back  toward  the  naso-pharynx.  In  rare  cases  it  may  be 
necessary  to  plug  the  posterior  nares  by  means  of  Belocq's 
cannula  or  a  soft  rubber  catheter.  Plugs  of  gauze  should 
never  be  let  in  the  nose  unchanged  for  more  than  24  hours. 

Differentiate  between  the  following  forms  of  inflam- 
mation: Serous,  sero=fibrinous,  sero=hemorrhagic. 

In  serous  inflammation  there  is  a  copious  exudation  of  fluid 
with  comparatively  little  cellular  matter. 

In  sero-fibrinous  inflammation  the  exudate  contains  more 
fibrin,  and  shows  a  marked  tendency  to  clot. 

In  sero-hemorrhagic  inflammation  the  exudate  contains 
large  numbers  of  red  blood  corpuscles,  and  is  correspondingly 
tinged. 

What  is  hare-lip?     Give  the  treatment  of  hare-lip? 

Hy  hare-lip  is  meant  a  congenital  fissure  of  the  upper  lip 
which  may  extend  for  a  variable  distance  through  the  soft 
tissues.     It  may  be  associated  with  a  cleft  in  the  palate. 


628  SURGERY. 

Treatment:  A  straight  bistoury  should  be  introduced  just 
above  the  angle  of  the  fissure,  and  both  sides  of  the  cleft 
pared  by  cutting  through  the  lip  in  a  crescentric  manner  so  as 
to  constitute  a  slight  angular  projection  or  prolabium  when 
the  freshened  surfaces  are  brought  into  apposition.  If  the 
nose  is  much  flattened  more  tissue  should  be  removed  from 
the  outer  than  from  the  inner  side,  so  that  when  the  parts  are 
sutured  together  the  nostrils  become  as  nearly  symmetrical 
as  possible.  By  paring  the  edges  in  a  curved  or  angular 
manner  the  depth  of  the  lip  is  increased  to  allow  for  subse- 
quent contraction.  Two  deep  silk-worm-gut  sutures  should 
be  introduced,  one  just  above  the  red  margin  and  one  close 
to  the  nose.  The  vermilion  borders  must  be  accurately  ap- 
proximated and  the  edges  of  the  wound  carefully  brought 
together  with  cat-gut  sutures.  The  dressing  consists  of  gauze 
and  collodion.  The  gauze  is  cut  in  the  shape  of  a  paddle,  the 
broad  ends  being  fastened  to  the  cheek.  This  should  be  so 
applied  as  to  prevent  tension  upon  the  wound.  The  silk- 
worm-gut sutures  are  removed  upon  the  fourth  day.  The 
operation  above  described  is  that  of  Malgaigne.  Other  opera- 
tions are  those  of  Nelaton,  Rose,  Mirault,  and  Konig.  Double 
hare-lip  may  sometimes  be  treated  by  operating  upon  each 
side,  as  in  a  unilateral  cleft,  but  if  the  os  incisivum  projects 
it  must  be  either  removed  or  replaced. 

Give  the  etiology  of  inflammation. 

Predisposing  local  causes:  Defective  circulation,  loss  or 
impairment  of  the  nervous  supply  of  a  part,  a  previous 
attack  of  inflammation. 

Predisposing  constitutional  causes:  Anything  producing 
an  impairment  of  the  general  health,  such  as  old  age,  weak 
action  of  the  heart,  an  unhealthy  condition  of  the  blood,  and 
the  presence  of  some  constitutional  disease. 

Exciting  causes:  Mechanical  irritants,  heat,  cold,  electric 
irritants,  toxic  irritants  (chemical,  vegetable,  animal),  and 
micro-organisms. 


SURGERY.  629 

Give  the  treatment  of  fracture  of  the  ribs. 

The  affected  side  should  be  firmly  strapped  with  strips  of 
adhesive  plaster  so  as  to  limit  its  range  of  motion.  These 
strips  (2  inches  in  width)  should  extend  beyond  the  median 
line  both  anteriorly  and  posteriorly,  and  are  to  be  applied 
from  below  upward,  each  strip  overlapping  above  one-half  of 
its  predecessor.  Each  strip  should  be  put  on  while  the  chest 
is  in  a  state  of  forcible  expiration.  If  the  patient  has  ad- 
vanced pulmonary  emphysema  or  chronic  bronchitis,  strap- 
ping is  not  advisable,  as  it  adds  to  the  respiratory  difficulty, 
and  in  such  a  case  the  patient  must  be  placed  in  bed  or 
propped  up,  and  the  fracture  left  to  take  care  of  itself. 
Strapping  is  also  contra-indicated  if  the  broken  fragments 
are  driven  inwards,  and  if  the  fracture  is  in  the  lower  part 
of  the  chest  and  the  pressure  irritates  the  diaphragm,  causing 
hiccough.  If  there  are  associated  injuries  of  the  thoracic 
viscera,  pneumo-thorax,  or  hemothorax,  they  must  be  appro- 
priately treated. 

Mention  the  varieties  of  hip=joint  dislocation,  and  de« 
scribe  in  detail  two  of  these  varieties. 

Dorsal,  dorsal  below  the  tendon  (sciatic),  thyroid,  and 
pubic. 

Dorsal  dislocation :  The  head  of  the  bone  lies  upon  the  dor- 
sum ilii,  the  trochanter  is  above  Nelaton's  line  and  nearer  to 
the  anterior  superior  spine,  the  ilio-tibial  band  is  relaxed,  and 
there  is  a  shortening  of  two  or  three  inches.  A  marked 
hollow  is  present  in  the  upper  part  of  Scarpa's  triangle,  and 
the  head  of  the  bone  cannot  be  felt  in  its  usual  position.  The 
thigh  is  flexed,  adducted,  and  inverted,  so  that  the  axis  of  the 
femur  crosses  the  lower  third  of  the  sound  thigh  and  the  ball 
of  the  toe  rests  upon  the  opposite  instep.  The  ligamentum 
teres  is  torn  and  the  capsule  is  lacerated.  The  small  external 
rotator  muscles  are  usually  lacerated,  as  may  also  be  the 
glutei  and  the  pectineus.  The  great  sciatic  nerve  may  be 
contused  or  compressed.  The  ileo-feraoral  ligament  is  un- 
injured. 


630  SURGERY. 

Dorsal  below  the  tendon  (sciatic)  :  The  signs  of  this  dis- 
location are  somewhat  similar  but  less  marked  than  in  the 
preceding  form.  There  is  not  so  much  shortening,  since  the 
intact  obdurator  internus  tendon  prevents  the  head  of  the 
bone  from  traveling  upward.  The  shortening  is  not  more 
than  one-half  inch  or  an  inch,  but  it  becomes  more  apparent 
upon  flexing  the  thigh  (Allis).  The  thigh  is  flexed,  ad- 
ducted,  and  inverted,  but  the  axis  of  the  femur  crosses  the 
opposite  knee  and  the  great  toe  rests  against  the  ball  of  the 
great  toe  of  the  sound  side.  The  head  of  the  bone  is  palpated 
with  great  difficulty  owing  to  the  greater  thickness  of  the 
gluteal  muscles  at  this  level.  Practically  the  same  muscles 
and  ligaments  are  injured  as  in  the  dorsal  variety.  The  head 
of  the  bone  is  below  the  tendon  of  the  obturator  internus. 
whereas  in  the  former  dislocation  it  is  above  it. 

Make  a  differential  diagnosis  of  coma  from  injury,  apo= 
plexy,  uremia,  opium  poisoning,  and  alcoholic  intoxication. 

Concussion :  The  individual  is  pale,  the  pulse  is  feeble  and 
fluttering,  the  respirations  are  sighing,  the  .skin  is  cold  and 
clammy,  and  the  urine  and  feces  may  be  passed  involuntarily. 
The  pupils  vary,  sometimes  being  unequal,  but  they  usually 
react  to  light.  Convulsions  occasionally  occur.  Paralysis  is 
not  present,  and  examination  of  the  extremities  may  give 
some  evidence  that  they  have  not  lost  their  sense  of  feeling. 
The  patient  can  usually  be  aroused  by  shouting. 

Compression :  The  iTuconseiousness  is  complete  and  the 
pupils  are  dilated  and  do  not  respond  to  light.  The  skin  in 
usually  hot  and  bathed  in  perspiration.  The  respirations  are 
slow,  stertorous,  and  have  a  peculiar  puffing  character,  due 
to  the  paralysis  of  the  muscles  of  the  cheeks.  The  bladder 
and  intestines  are  usually  paralyzed,  but  the  incontinence  of 
retention  may  be  present.  The  pulse  is  slow,  full,  and  fre- 
quently irregular.  The  whole  body  may  be  paralyzed,  but 
hemiplegia  is  the  form  most  commonly  observed.  Mono- 
plegias also  occur,  and  are  extremely  valuable  from  the 
standpoint  of  localization. 


SURGERY.  631 

Apoplexy :  Absolute  unconsciousness,  stertor,  hemiplegia 
or  complete  paralysis  are  present.  Aid  in  the  diagnosis  is 
furnished  by  the  age  of  the  patient  and  the  condition  of  the 
arteries.  The  temperature  is  usually  higher  in  one  axilla, 
and  conjugate  deviation  may  be  observed.  The  face  is 
flushed,  the  conjuctiva  is  injected,  the  pulse  is  full  and  slow, 
and  the  breathing  is  stertorous.  Urine  and  feces  may  be 
passed  involuntarily,  and  convulsive  seizures  are  not  infre- 
quent. 

Uremia:  Paralysis  and  stertor  are  absent  (unless  apoplexy 
co-exists) .  The  legs  may  be  edematous  and  the  urine  contains 
albumin  and  casts.  The  breath  is  urinous,  arterial  tension  is 
high,  and  the  aortic  second  sound  is  accentuated. 

Opium  poisoning:  Paralysis  is  not  present,  and  the  pupils 
are  pin-point  and  will  not  dilate.  The  odor  of  laudanum 
may  be  detected  upon  the  breath.  The  pulse  and  respira- 
tions are  slow. 

Alcoholic  intoxication :  Unconsciousness  is  not  complete 
and  it  is  usually  possible  to  arouse  the  patient.  Some  aid 
may  be  furnished  by  the  appearance  of  the  patient,  but  this 
is  frequently  misleading.  Although  the  breath  may  be  alco- 
holic, it  must  be  remembered  that  alcohol  may  have  been 
given  in  an  attempt  to  revive  the  individual.  The  pupils  are 
usually  contracted  but  dilate  when  the  patient  is  aroused. 
The  temperature  is  generally  subnormal. 

Give  the  symptoms  and  treatment  of  hammer=toe. 

Symptoms:  llyperextension  of  the  first  phalanx,  flexion  of 
the  second  to  an  acute  angle,  and  either  flexion  or  extension 
of  the  terminal  phalanx.  The  first  interphalangeal  joint  rubs 
against  the  upper  leather  of  the  shoe,  and  the  patient  walks 
upon  the  extremity  of  the  terminal  phalanx.  Corns  are  pres- 
ent over  the  head  of  the  first  phalanx,  causing  great  pain 
and  discomfort.  The  affection  is  most  frequently  observed 
in  the  second  toe. 

Treatment:  If  the  case  is  seen,  early,  treatment  may  be 
commenced  with  the  wearing  of  correctly  shaped  boots,  but 


632  SURGERY. 

the  affection  has  usually  progressed  so  far  that  the  excisioa 
of  the  first  interphalangeal  joint  or  amputation  of  the  toe  is 
required.  The  first  operation  is  the  preferable  one,  since 
amputation  is  frequently  followed  by  hallux  valgus. 

Describe  dermoid  cysts.  In  what  situations  are  they 
most  commonly  found? 

Dermoid  cysts  are  cysts  composed  of  structures  which 
naturally  belong  to  the  skin  or  mucous  membranes,  but  which 
occur  in  situations  where  these  structures  are  not  normally 
found.  They  may  contain  all  the  elements  of  the  skin,  such 
as  stratified  epidermis,  a  papillary  layer,  and  even  subcuta- 
neous connective  tissue.  Hair  follicles  and  sebaceous  glands 
are  frequent,  and  hairs  of  varying  lengths  are  almost  always 
present.  Some  forms  of  dermoids  contain  teeth,  nerve  tissue, 
muscle,  and  bone,  and  structures  resembling  intestine  are  not 
of  uncommon  occurrence.  They  have  been  classified  hy 
Bland  Sutton  into  sequestration  dermoids,  tubulo-dermoids, 
and  ovarian  dermoids. 

Dermoid  cysts  are  found  in  the  ovary,  in  the  testicle,  in  the 
peritoneum,  at  the  outer  angle  of  the  orbit,  above  the  nose,  in 
the  neck,  in  the  floor  of  the  mouth,  in  the  membranes  of  the 
brain,  and  elsewhere. 

Describe  suprapubic  lithotomy. 

A  silver  catheter  is  introduced  into  the  bladder  which  is 
to  be  filled  with  about  ten  ounces  of  a  3%  solution  of  borie 
acid.  Some  surgeons  still  distend  the  rectum  by  the"  intro- 
duction and  subsequent  filling  of  a  rubber  bag.  This  is 
hardly  necessary,  but  if  the  operator  employ  the  rectal  bag 
it  should  never  contain  more  than  8  ounces,  it  should  be 
inserted  after  the  catheter  has  been  introduced  into  the 
bladder,  and  before  the  bladder  is  distended  with  the  boric 
acid  solution.  An  incision  about  2i/2  inches  in  length  is  made 
in  the  median  line  just  above  the  symphysis  and  is  subse- 
quently earried  down  to  the  areolar  tissue  in  front  of  the 
bladder.  If  the  peritoneum  bulges  into  the  upper  angle  of 
the  wound  it  should  be  displaced  upward  out  of  harm's  way. 


SURGERY.  633- 

There  should  be  no  difficulty  in  recognizing  the  bladder  when 
distended  and  containing  the  curved  end  of  the  silver  cathe- 
ter. Two  silk  ligatures  are  now  passed  through  the  bladder- 
wall  and  the  bladder  is  opened  between  them  by  a  quick 
thrust  of  the  knife.  The  index-finger  is  passed  into  the  wound 
and  locates  the  stone,  which  is  to  be  removed  by  the  finger, 
by  the  scoop,  or  by  forceps. 

Give  the  symptoms  and  treatment  of  any  one  form  of 
acute  intestinal  obstruction. 

Strangulated  hernia.  Symptoms :  Pain  at  the  hernial  ori- 
fice and  radiating  toward  the  umbilicus.  The  hernia  is  hard, 
tense,  and  gives  no  impulse  on  coughing.  Vomiting  which  is 
projectile,  without  preceding  nausea,  at  first  gastric,  then 
bilious  and  soon  assuming  a  stercoraceous  character.  Abso- 
lute  constipation.     Shock.     Subnormal   temperature. 

Treatment:  Immediate  herniotomy. 

Give  any  one  of  the  dislocations  of  the  knee-joint  and 
the  method  of  reduction. 

The  anterior  dislocation  of  the  upper  end  of  the  tibia. 

The  thigh  should  be  flexed  upon  the  pelvis,  extension  is 
made  upon  the  leg,  and  the  surgeon  endeavors  to  bring  the 
bones  into  their  normal  relation  by  pressure  and  manipula- 
tion. The  parts  should  be  massaged  from  the  first,  but 
passive  motion  should  not  be  employed  until  the  end  of  the 
second  week  and  then  with  great  caution.  The  patient  should 
subsequently  wear  an  artificial  knee-cap  to  prevent  a  recur- 
rence of  the  displacement. 

Define  necrosis  and  give  the  cause  and  surgical  treat- 
ment. 

By  necrosis  is  meant  the  death  of  bone  in  mass. 

Causes.  Denudation  of  periosteum.  Periostitis,  ostitis,  or 
osteomyelitis.  Tuberculosis.  Syphilis.  Exposure  to  the 
fumes  of  phosphorus.  The  excessive  administration  of 
mercury. 

Surgical  treatment:  Sequestrotomy. 


634  SURGERY. 

Give  the  symptoms  of  shock,  and  state  when  the  prog= 
nosis  is  grave. 

Syinptoms.  The  skin  is  pale,  cool,  and  bathed  in  perspira- 
tion, the  pulse  is  rapid  and  weak,  the  respirations  are  shallow 
and  irregTilar.  and  the  temperature  is  subnormal.  Nausea 
and  vomiting  may  occur,  and  the  feces  and  urine  may  be 
passed  involuntarily.  The  symptoms  vary  according  to  the 
severity  of  the  injury,  and  the  patient  may  suffer  from  any- 
thing from  a  sensation  of  momentary  weakness  and  faintness 
to  a  most  profound  muscular  relaxation  and  unconsciousness. 

The  prognosis  is  grave  when  a  vital  part  is  injured,  when 
the  injury  is  extensive,  entailing  a  continued  source  of  irrita- 
tion and  depression,  when  a  reaction  as  regards  temperature 
is  not  observed  within  four  hours  after  the  reception  of  the 
injury,  when  large  quantities  of  blood  have  been  lost,  and  in 
old  people  who  are  the  subjects  of  degenerative  changes. 

How  would  you  proceed  surgically  to  remove  the  fluid 
in  a  case  of  ascites? 

The  patient  is  seated  in  a  chair  and  the  abdomen  is  encir- 
cled w^ith  a  flannel  binder,  the  ends  of  which  are  split  to 
within  six  inches  of  the  median  line.  The  untorn  portion  of 
the  binder  is  placed  over  the  front  of  the  abdomen  and  the 
divided  ends  are  crossed  behind  and  held  by  assistants  so  as 
to  make  continuous  pressure  upon  the  abdominal  contents. 
A  spot  is  selected  in  the  median  line  below  the  umbilicus 
where  absolute  dulness  is  obtained  upon  percussion.  After 
all  aseptic  precautions  have  been  observed,  the  skin  over  this 
small  area  is  anesthetized  by  a  drop  of  carbolic  acid  or  by  the 
intradermic  injection  of  Schleieh's  solution,  a  small  incision 
is  made  through  the  skin,  and  a  suitable  trochar  and  cannula 
is  inserted.  The  fluid  should  be  withdrawn  slowly,  continu- 
ous pressure  being  made  upon  the  abdominal  contents  by 
means  of  the  flannel  binder.  All  of  the  fluid  should  not  be 
withdrawn.  After  the  withdrawal  of  the  cannula  the  small 
wound  should  be  closed  with  aseptic  gauze  and  sterile  col- 
lodion. 


SURGERY.  .  635 

Differentially  diagnosis  impacted  and  non-impacted  frac> 
ture  of  the  neck  of  the  femur. 

Impacted  Fracture.  Non-impacted  Fracture. 

Crepitus  is  absent.  Crepitus  may  be  obtained, 

Eversion  is  less  marked  and  inver-  Eversion  is  present. 

sion  may  be  present  (rare). 

The  head  of  the  femur  moves  under  The   head   of  the   femur   does   not 

the  finger  when  the  extremity  is  move  under  the  finger  when  the 

rotated.  extremity  is  rotated. 

The  shortening  is  not  overcome  by  Shortening   is   overcome   by  exten- 

moderate   extension    (danger!).  sion. 

The  symptoms  of  fracture  are  not  The    symptoms     of     fracture     are 

so  marked.  more  marked. 

The    individual    may    be    able    to  The  individual  is  unable  to  walk. 

walk   (do  not  allow  her  to  try). 

Name  and  describe  the  different  varieties  of  fracture. 

Simple  (subcutaneous)  :  No  communication  with  external 
air. 

Compound  (open)  :  Communication  with  external  air. 

Complete :  The  entire  thickness  of  the  bone  is  involved. 

Incomplete :  The  entire  thickness  of  the  bone  is  not  in- 
volved. 

Multiple:  The  bone  is  fractured  in  more  than  one  place 
and  the  lines  of  fracture  do  not  communicate. 

Single :  The  bone  is  fractured  in  but  one  place. 

Comminuted :  The  bone  is  fractured  into  a  number  of  frag- 
ments and  the  lines  of  fracture  communicate  with  each  other. 

Complicated:  In  addition  to  the  fracture,  a  neighboring 
joint  is  dislocated,  the  main  artery  or  nerve  of  the  extremity 
is  injured,  or  there  is  a  severe  laceration  of  the  soft  parts. 

Fissured:  A  linear  split  without  displacement. 

Stellate :  The  lines  of  fracture  radiate  from  a  central  point. 

Depressed:  There  is  a  crushing-in  of  a  portion  of  the  bone. 

Impacted :  One  fragment  is  driven  into  the  other. 

Apophyseal :  A  separation  of  a  scale  of  bone  to  which  a 
ligament  or  tendon  is  attached. 

Longitudinal,  transverse,  oblique,  and  spiral:  The  desig- 
nations indicate  the  directions  of  the  line  of  fracture. 


636  SURGERY. 

Give  the  general  symptoms  of  brain  tumor. 

Headache,  pain  upon  percussion,  vomiting,  vertigo,  epi- 
leptic convulsions,  choked  disc,  and  finally,  symptoms  of  com- 
pression. 

Describe  an  operation  for  the  cure  of  webbed  fingers. 

Didot's  operation.  After  all  aseptic  precautions  have  been 
observed,  a  flap  the  length  of  the  finger  and  half  its  width 
(plus  the  added  width  of  the  web)  is  taken  from  the  dorsal 
surface  of  one  finger  and  the  palmar  surface  of  the  other. 
Each  of  these  flaps  is  carefully  applied  to  the  denuded  area 
upon  the  finger  to  which  it  is  attached  and  secured  by  sutures. 

How  is  resection  of  the  eIbow=point  performed? 

After  all  aseptic  precautions  have  been  observed,  the  fore- 
arm is  flexed  to  a  right  angle  and  held  across  the  chest  of  the 
patient  by  an  assistant.  A  vertical  incision  five  inches  in 
length  is  now  made  along  the  back  of  the  joint,  the  center  of 
the  incision  being  a  line  or  two  to  the  inner  side  of  the  tip  of 
the  olecranon.  This  incision  goes  down  to  the  bone  and  di- 
vides the  tendon  of  the  triceps  longitudinally.  The  tendon 
is  then  separated  from  the  olecranon  and  this  process  cleared 
off,  keeping  the  knife  close  to  the  bone  to  avoid  wounding  thfr 
ulnar  nerve  on  the  inner  side  and  the  extension  of  the  triceps 
upon  the  outer  side.  The  olecranon  is  now  cut  through  and 
removed.  With  the  thumb  in  the  wound  to  protect  the  soft 
parts,  the  structures  are  gradually  separated  from  the  inter- 
nal eondyle  by  the  knife  (cutting  towards  the  bone)  or 
periosteal  elevator.  In  this  manner  the  common  flexor  tendon 
is  separated  from:  the  bone  and  the  internal  lateral  ligament 
is  divided.  The  external  condyle  is  now  freed  in  a  similar 
manner,  and  the  end  of  the  humerus  is  protruded  through  the 
wound  by  flexing  the  forearm  until  it  touches  the  arm.  The 
articular  surface  of  the  humerus  is  now  sawn  off,  and  if  any 
carious  areas  are  seen  upon  the  surface  of  section  they  are  to 
be  thoroughly  gouged  out.  The  bones  of  the  forearm  are  then 
forced  through  the  wound  and  their  eartilaginous  surfaces 


SURGERY.  637 

removed.  Care  must  be  taken  not  to  injure  the  insertions  of 
the  biceps  and  brachialis  antieus.  All  diseased  synovial  mem- 
brane and  granulation  tissue  must  be  dissected  away,  any  ex- 
isting sinuses  thoroughly  curetted,  and  the  parts  flushed  with 
an  antiseptic  solution.  A  drainage  tube  is  inserted  in  the 
most  dependent  portion  of  the  wound,  sutures  are  introduced, 
and  an  aseptic  dressing  applied. 

Give  the  symptoms  and  treatment  of  naevus. 

Capillary  naevus  occurs  in  the  form  of  a  slightly  elevated 
mass,  which  varies  in  color  from  purple  to  bright  red,  ac- 
cording to  the  relative  amount  of  contained  venous  or  arte- 
rial blood.  These  growths  are  congenital  or  occur  soon  after 
birth,  they  may  be  multiple,  and  rarely  exceed  an  inch  or  two 
in  diameter.  They  are  usually  found  upon  the  neck  or  face. 
They  may  shrink  and  disappear,  persist  unchanged,  or 
rapidly  increase  in  size.    Treatment :  Excision  or  electrolysis. 

Cavernous  naevus  usually  involves  both  skin  and  subcuta- 
neous connective  tissue.  It  usually  occurs  as  a  lobulated 
bluish  or  dusky  red  swelling,  soft  to  the  touch,  easily  com- 
pressible, but  refilling  upon  the  removal  of  the  pressure. 
Pulsation  and  bruit  are  usually  absent.  Treatment :  Excision 
wherever  practical.  Electrolysis  when  the  growth  cannot 
be  excised. 

What  is  glaucoma?    Give  the  treatment  of  glaucoma. 

Glaucoma  is  a  disease  of  the  eye  characterized  by  increased 
intra-ocular  tension,  excavation  of  the  optic  disc,  restriction 
of  the  field  of  vision,  corneal  anesthesia,  colored  halos  about 
lights,  and  diminution  of  visual  power  that  may  result  in 
blindness.     Treatment:  Iridectomy. 

What  is  a  tumor? 

A  tumor  is  an  atypical  new  growth  which  is  not  the  result 
of  inflammation. 

A  tumor  is  an  adventitious  mass  of  tissue,  differing  from 
the  tissue  in  which  it  grows  in  gross  and  minute  structure, 
tending  to  unlimited  growth,  having  no  function,  the  nutri- 


638  SURGERY. 

tion  of  which  is  independent  of  the  general  nutrition  of  the 
body,  showing  no  tendency  to  spontaneous  cure,  and  not  co- 
incident with  nor  dependent  upon  inflammation. 

Describe  the  following;  forms  of  sutures:  Interrupted, 
button,  continued,  buried,  secondary. 

The  interrupted  suture  consists  of  a  number  of  single 
stitches,  each  one  being  independent  of  its  neighbor. 

The  button  suture  is  made  by  inserting  a  needle  threaded 
with  stout  silver  wire  at  some  distance  from  the  wound,  carry- 
ing it  deeply  through  the  tissues  and  bringing  it  out  at  a  cor- 
responding point  on  the  opposite  side  of  the  wound.  The 
suture  is  secured  at  both  ends  to  a  flat  lead  button,  the  wire 
being  pulled  as  tight  as  is  deemed  advisable. 

In  a  continued  suture  the  suture  traverses  the  wound  con- 
tinuously in  the  same  direction,  being  tied  only  at  the  begin- 
ning and  at  the  end. 

A  buried  suture  is  one  completely  covered  by  and  not  in- 
volving the  skin. 

Secondary  sutures  are  those  which  are  introduced  at  some 
time  (usually  two  or  three  days)  subsequent  to  an  operation. 

What  are  the  causes  of  atony  of  the  bladder? 

Chronic  over-distension  from  obstructed  outflow  (enlarged 
prostate,  stricture),  a  single  prolonged  voluntary  or  involun- 
tary over-distension,  cystitis  (particularly  when  gonorrheal), 
senility,  and  infective  fevers. 

What  is  the  treatment  of  fracture  united  with  de= 
formity? 

Osteotomy  or  osteoclasis.  If  the  deformity  is  not  great  no 
treatment  may  be  required. 

Give  the  treatment  for  rattlesnake  bite. 

If  the  bite  has  been  received  upon  a  limb,  a  ligature  should 
be  immediately  thrown  around  the  part  above  the  wound  and 
drawn  tight  enough  to  prevent  the  entrance  of  the  venom 
into  the  circulation.     The  wounded  area  should  then  be  freely 


SURGERY.  689 

excised  and  bleeding  encouraged  for  a  short  time.  If  the 
bite  is  upon  a  portion  of  the  body  which  cannot  be  constricted 
by  a  ligature  the  wound  should  be  excised  as  before,  or  if  this 
is  impracticable  vigorous  suction  of  the  wound  should  be 
made.  In  the  case  of  an  extremity  the  ligature  is  to  be  slack- 
ened at  intervals  to  allow  of  the  admission  of  any  remaining 
poison  by  instalments.  Excision  of  the  wound  and  the  thor- 
ough rubbing-in  of  crystals  of  potassium  permanganate  has 
been  highly  recommended.  The  constitutional  treatment  is 
largely  symptomatic.  If  the  proper  antivenom  be  at  hand  it 
should  be  employed.  Hypodermatic  injections  of  strychnine 
are  usually  required  and  large  doses  of  alcohol  are  believed  to 
be  efficacious  by  some.  Artificial  respiration,  inhalations  of 
oxygen,  adrenalin,  ammonia,  ether,  and  digitalis  may  also  be 
required. 

What  circumstances  demand  amputation  of  an  ex  = 
tremity? 

Amputation  is  demanded:  1.  To  trim  up  a  stump  of  a  limb 
torn  off  by  machinery,  cut  off  by  wheels  of  a  railway  train, 
or  carried  away  by  a  cannon-ball ;  2.  When  the  entire  limb  or 
one  of  its  segments  has  been  totally  disorganized ;  3.  AVhere 
gangrene  is  imminent  or  has  supervened  (particularly  if  it  is 
of  the  spreading  type)  :  4.  When  marked  symptoms  of  sepsis 
make  their  appearance  or  exhaustion  supervenes  from  sup- 
puration, in  a  case  where  an  unsuccessful  attempt  has  been 
made  to  save  a  doubtful  limb ;  5.  In  severe  compound  lacera- 
tions of  the  foot  in  old  people,  laying  open  the  common  syn- 
ovial cavity  and  involving  the  bones;  6.  By  primary  malig- 
nant growths  of  bone  (sarcoma) . 

Amputation  mny  be  required  for  the  relief  of  deformity, 
for  the  removal  of  benign  gro\^'ths  (enchondroma  of  fingers), 
for  laceration  of  the  main  artery  of  the  limb,  with  other  grave 
lesions  of  the  soft  parts,  and  in  cases  whore  the  limb,  if  saved, 
would  be  of  no  practical  use. 


640  SURGERY. 

Define  the  terms  thrombus,  phlebitis,  and  varix,  and 
give  the  causes  of  each. 

A  thrombus  is  a  clot  of  blood  formed  within  the  heart  or 
blood-vessels.  It  is  due  to  alterations  in  the  blood  current, 
changes  in  the  vessel-walls,  and  alterations  in  the  blood  itself. 

By  phlebitis  is  meant  the  inflammation  of  a  vein.  It  may 
be  due  to  injury  of  the  coat  of  the  vein,  to  the  formation  of  a 
thrombus  within  the  vein,  to  the  extension  of  an  inflammation 
from  surrounding  tissues,  to  gout,  or  to  infection  with  pyo- 
genic organisms. 

By  varix  is  meant  a  dilated,  elongated,  and  more  or  less 
tortuous  condition  of  a  vein.  It  is  due  to  increased  pressure 
within  the  veins  (long  standing,  habitual  over-exertion,  tight 
garters),  abstraction  or  occlusion  of  the  deeper  veins,  and  to 
an  abnormal  communication  with  an  artery  (aneurysmal 
varix) .  Inherited  weakness  and  the  relaxation  of  the  system 
from  sedentary  habits  are  predisposing  causes. 

Describe  a  chancroid.  Give  its  usual  symptoms  and 
possible  complications. 

A  chancroid  is  an  infectious  venereal  sore  characterized  by 
the  absence  of  constitutional  manifestations.  It  commences 
as  a  pustule  or  ulcer,  is  frequently  multiple,  is  round,  oval, 
or  unsymmetrically  irregular,  is  excavated  or  "  punched 
out,"  has  a  rough  "worm-eaten"  whitish-gray  surface,  se- 
cretes an  abundant  purulent  discharge  which  is  readily  auto- 
inoculable,  runs  an  irregular  course,  is  painful,  and  usually 
responds  to  local  treatment.  The  possible  complications  are 
phimosis,  paraphimosis,  lymphangitis,  and  bubo. 

What  is  a  dislocation?  Define  the  various  kinds  of 
dislocation. 

A  dislocation  is  a  displacement  of  one  or  more  bones  of  a 
joint  from  its  natural  position.  It  is  also  the  displacement 
of  any  organ  from  its  natural  position. 

Traumatic,  due  to  violence  or  muscular  action. 

Pathologic,  due  to  disease. 


SURGERY.  641 

Congenital,  due  to  an  erroi*  of  development,  as  a  result  of 
which  a  normal  relation  of  the  bony  constituents  has  never 
existed.  (The  term  "congenital  dislocation"  is  a  misnomer; 
it  is  a  congenital  malformation.) 

What  are  the  methods  of  controlling  hemorrhage? 

Exposure  to  air,  cold,  hot  water,  elevation,  direct  pressure, 
styptics,  cauterization,  acupressure,  forcipressure,  suture, 
torsion,  and  ligation. 

Define  hypertrophy  and  give  the  causes. 

Hypertrophy  is  an  increase  in  bulk  of  a  tissue  or  organ 
occurring  independently  of  the  general  growth  of  the  body 
and  without  any  structural  change  of  the  part  affected.  In 
a  true  hypertrophy  the  function  is  increased. 

Causes:  Congenital  predisposition,  removal  of  pressure, 
direct  stimulation  or  intermittent  pressure,  disturbances  of 
nutrition,  increased  functional  demand,  and  disturbances  of 
the  nervous  system. 

Give  the  surgical  palliative  treatment  of  carcinoma  of 
the  stomach  at  the  pylorus. 

Gastro-enterostomy,  preferably  by  Von  Hacker's  method 
(posterior  gastro-enterostomy). 

Mention  the  causes  of  delayed  union  and  give  the  treat- 
ment. 

The  constitutional  causes  are  general  debility,  osteomalacia, 
scurvy,  syphilis,  senility,  pregnancy,  and  the  cancerous 
cachexia. 

The  local  causes  are  faulty  apposition,  the  interposition  of 
fluid,  muscle,  or  aponeurosis  between  the  fragments,  want  of 
rest,  defective  blood  supply,  defective  innervation,  inflamma- 
tion on  the  surface  of  the  limb,  faulty  treatment,  and  local 
affections  of  bone  (malignant  tumors,  destruction  of  the  peri- 
osteum by  inflammation). 

Treatment:  The  removal  of  any  local  cause  and  the  appro- 
priate remedies  for  the  underlying  constitutional  disturbance. 
41 


642  SURGERY. 

Change  of  air,  tonics,  regulation  of  the  diet,  and  the  adminis- 
tration of  the  mineral  acids  will  frequently  effect  a  speedy 
union. 

What  glandular  structures  are  most  commonly  affected 
in  carcinoma  of  the  anterior  portion  of  the  tongue? 

The  submental  lymphatic  glands,  the  submaxillary  lym- 
phatic glands,  and  probably  those  lying  beneath  the  sterno- 
mastoid  muscles.  The  sublingual  and  submaxillary  salivarj^ 
glands  may  also  be  involved. 

What  are  the  causes  of  ptosis  and  the  remedial  meas= 
ures  employed? 

Paralysis  of  the  oculo-motor  nerve  or  its  supra-orbital 
branch  (syphilis,  rheumatism),  and  faulty  development  or 
injury  of  the  levator  palpebrae. 

Treatment:  If  due  to  syphilis  or  rheumatism  the  appro- 
priate constitutional  treatment  is  to  be  instituted.  In  the 
absence  of  constitutional  causes,  operations  are  performed  to 
increase  the  vicarious  action  of  the  frontalis  muscles  upon  the 
upper  lid  (Panas.)  Wilder  folds  the  tarso-orbital  fascia  upon 
itself  and  establishes  a  firm  adhesion  between  the  fascia  and 
the  frontalis  muscle.  If  the  action  of  the  levator  muscle  is 
not  entirely  lost  the  principles  of  tendon  advancement  and 
tendon  resection  may  be  employed.  (Everbusch,  Snellen, 
Wolff.) 

What  articular  changes  take  place  in  dislocation? 
What  are  the  general  principles  governing  the  treatment 
of  dislocation? 

One  or  more  of  the  ligaments  and  the  capsule  of  the  joint 
are  torn  and  the  mutual  relations  of  the  articular  ends  of  the 
bones  are  changed.  If  the  dislocation  remains  unreduced 
the  cavity  of  the  joint  becomes  filled  with  granulation  tissue 
and  the  displaced  and  lacerated  connective  tissues  become 
condensed  about  the  head  of  the  dislocated  bone,  sometimes 
forming  a  new  capsule.  Any  irregularities  of  the  dislocated 
bone  become  rounded  off  and  it  contracts  adhesions  to  the 


SURGERY.  643 

surrounding  tissues  or  forms  a  new  joint  by  resting  against 
a  bony  surface,  its  pressure  stimulating  the  bone  and  peri- 
osteum to  the  production  of  an  osseous  ring  about  the  point 
of  contact,  which  possibly  becomes  covered  with  fibro-car- 
tilage. 

Principles  of  treatment:  Relaxation  of  the  muscles  about 
the  joint,  the  reduction  of  the  dislocation  by  causing  the  dis- 
located bone  to  enter  the  capsule  through  the  same  rent  which 
it  made  upon  leaving  it  (by  manipulation,  or  by  extension 
and  counter-extension),  the  fixation  of  the  parts  after  reduc- 
tion for  a  sufficient  length  of  time,  and  subsequent  passive 
and  active  motion. 

Define  a  fracture.  Give  the  causes,  symptoms,  and 
varieties  of  fracture. 

A  fracture  is  a  sudden  solution  of  continuity  of  a  bone. 

Predisposing  causes :  Advancing  age,  male  sex,  and  dis- 
eased conditions  of  the  bone  (atrophy,  fragilitas  ossium, 
rickets,  sarcoma,  secondary  cancer). 

Exciting  causes:  Direct  violence,  indirect  violence,  and 
muscular  action. 

Symptoms:  A  new  point  of  motion  (preternatural  mobil- 
ity), crepitus,  deformity  from  displacement,  partial  or  com- 
plete loss  of  function,  and  signs  of  local  trauma. 

Varieties:  Complete  and  incomplete.  Simple  (subcutan- 
eous), compound  (open),  single,  multiple,  complicated,  com- 
minuted, and  impacted.  Linear,  stellate,  longitudinal, 
transverse,  and  spiral. 

What  diseases  attack  the  antrum  maxillae  (Highmore)? 

Hydrops,  empyema,  benign  tumors  (chrondroma,  fibroma, 
myxoma,  osteoma),  and  malignant  tumors  (sarcoma  and 
carcinoma). 

When  do  the  secondary  symptoms  of  syphilis  normally 
appear?     When  do  the  tertiary  symptoms  appear? 

The  secondary  symptoms  of  syphilis  normally  appear  from 
six  to  ten  weeks  after  the  beginning  of  the  infecting  chancre. 


644  SURGERY. 

Tertiary  symptoms  may  appear  within  six  months  of  in- 
fection or  not  for  twenty  or  thirty  years.  The  time  of  their 
appearance  is  largely  dependent  upon  the  treatment  received 
'by  the  patient.  In  some  cases  w^hich  have  been  correctly 
treated  they  may  never  make  their  appearance. 

Give  a  resume  of  the  constitutional  and  the  local  treats 
ment  of  inflammation. 

Constitutional  treatment:  Rest,  good  hygiene,  proper  diet, 
purgatives,  emetics,  arterial  sedatives,  diaphoretics,  diuretics, 
venesection,  hynotics,  narcotics,  alteratives,  stimulants,  and 
tonics. 

Local  treatment :  Rest,  position,  heat,  cold,  counter-irrita- 
tion, local  blood-letting  (scarifications,  leeches,  wet  cups), 
moisture,  stimulants,  astringents,  antiseptics,  alteratives,  in- 
cisions, surgical  operations,  compression,  and  massage. 

Differentially  diagnosis  chancre,  chancroid,  and  herpes 
progenitalis. 

Chancre  has  a  period  of  incubation  not  less  than  ten  days ; 
commences  as  an  erosion,  tubercle,  papule,  or  ulcer;  is  single, 
or  simultaneously  multiple ;  is  round,  oval,  or  symmetrically 
irregular;  is  usually  cup-shaped,  saucer-shaped,  or  elevated; 
has  a  smooth  shining  red  or  glazed  surface,  and  may  be  cov- 
ered by  a  diphtheritic  membrane  or  scab ;  has  scanty,  serous 
secretion  which  is  practically  never  auto-inoculable ;  is  almost 
always  indurated  (cartilaginous  or  parchment-like),  the  in- 
duration being  circumscribed  and  disappearing  under  appro- 
priate treatment;  is  accompanied  by  little  or  no  pain,  and 
often  heals  spontaneously. 

Chancroid  has  no  period  of  incubation ;  commences  as  a 
pustule  or  ulcer;  is  often  multiple  (frequently  by  auto- 
inoculation)  ;  is  round,  oval,  or  unsymmetrically  irregular 
(with  borders  described  by  segments  of  large  circles)  ;  is 
hollow,  excavated,  or  punched  out;  has  a  rough,  "worm- 
eaten,"  whitish-gray  surface;  has  an  abundant,  muco-puru- 
lent  secretion  (readily  auto-inoculable)  ;  is  only  exceptionally 


SURGERY.  645 

indurated   (induration  shades  off  into  surrounding  tissues)  ; 
is  painful,  and  runs  an  irregular  course. 

Herpes  progenitalis  has  no  period  of  incubation,  commences 
as  a  group  of  vesicles  which  may  coalesce ;  is  multiple,  is 
irregular  in  shape  (edges  described  by  segments  of  small 
circles),  is  always  superficial,  has  a  moderate  amount  of 
secretion  (auto-inoculable  with  difficulty),  has  no  more  in- 
duration than  any  local  ulcer,  is  painful,  and  usually  heals 
promptly  under  mild  treatment.  (Condensed  from  Keen 
and  ^Vhite.) 

How  would  you  diagnosis  and  reduce  a  backward  dis= 
location  of  the  forearm? 

The  forearm  is  shortened,  semiflexed,  and  midway  between 
pronation  and  supination.  The  forearm  cannot  be  flexed 
upon  the  arm.  The  olecranon  is  unduly  prominent  behind 
the  joint,  and  above  it  is  a  depression  in  which  the  tendon 
of  the  triceps  may  be  palpated.  The  head  of  the  radius  may 
be  detected  as  a  globular  swelling  behind  the  external  con- 
dyle. The  lower  end  of  the  humerus  forms  a  broad  promi- 
nence in  front  of  the  articulation.  This  dislocation  is  dis- 
tinguished from  a  supraoondyloid  fracture  by  the  following 
points:  the  olecranon  is  behind  a  line  connecting  the  two 
condyles,  the  condyles  do  not  move  with  the  displaced  ole- 
cranon, the  distance  between  the  acromion  and  the  external 
condyle  remains  unaltered,  and  crepitus  is  absent. 

Reduction :  The  patient  is  seated  in  a  chair,  the  surgeon 
places  his  foot  upon  the  chair  with  his  knee  in  the  bend  of 
the  elbow,  and  presses  against  the  lower  end  of  the  humerus, 
at  the  same  time  fixing  the  bones  of  the  forearm  by  grasping 
them  just  above  the  wrist.  When  this  pressure  has  been 
maintained  for  some  time,  the  forearm  is  slowly  and  forcibly 
flexed  upon  the  arm.  By  this  procedure  the  interlocking  bony 
prominences  are  disengaged  and  reduction  is  effected. 

What  are  the  principal  causes  of  tinnitus  aurium? 

Acute  otitis  media,  chronic  catarrhal  otitis  media,  chronic 


646  SURGERY. 

suppurative  otitis  media,  neurosis  of  the  auditory  nerve, 
Meniere's  disease,  impacted  cerumen,  anemia,  alterations  in 
pressure  in  the  labyrinth,  obstruction  of  the  Eustachian  tube, 
and  large  doses  of  quinine  or  of  the  salicylates. 

What  are  the  most  approved  operative  procedures  in 
the  treatment  of  varicose  veins  of  the  lower  extremity? 

Excision  of  the  entire  vein,  excision  of  a  number  of  sections 
of  the  vein,  excision  of  a  portion  of  the  internal  saphenous 
vein  (in  certain  cases),  and  complete  division  and  double 
ligation  of  all  the  superfieal  veins  at  the  junction  of  the 
upper  and  middle  thirds  of  the  leg  (Schede's  operation). 

What  is  coxa  vara  and  describe  an  operation  for  its  cor= 
rection. 

An  incurvation  or  bending  of  the  neck  of  the  femur.  There 
is  a  diminution  of  the  normal  angle  between  the  neck  and  the 
shaft  of  the  bone. 

Linear  osteotomy  of  the  femoral  shaft  just  below  the  lesser 
trochanter.  A  slender  osteotome  is  pushed  through  a  small 
incision  upon  the  outer  side  of  the  thigh  and  brought  in  con- 
tact with  the  femur.  The  cutting  edge  is  now  turned  at 
right  angles  to  the  bone  and  the  cortical  substance  cut  until 
about  one-half  of  the  circumference  has  been  divided.  After 
fracturing  the  remaining  bony  tissue,  the  shaft  of  the  femur 
is  rotated  inward  until  the  foot  assumes  its  normal  position. 
The  extremity  should  next  be  abducted  to  the  normal  limit 
and  a  spica  bandage  of  plaster  carefully  applied  so  that  it 
extends  from  the  axilla  to  the  toes. 

Give  the  symptoms  necessitating  fixation  of  a  floating 
kidney  and  describe  the  operation. 

Absolute  indications.  Marked  local  symptoms  such  as 
constant  pain  or  soreness  in  the  kidney,  renal  crises,  albumin 
or  blood  casts  in  the  urine,  and  intermittent  hydronephrosis. 

Relative  indication.  Distressing  reflex  symptoms  not  re- 
lieved by  symptomatic  treatment. 

The  patient  should  be  in  the  prone  position  with  Edebohl's 
air-cushion  exactly  beneath  the  epigastrium.    After  all  aseptic 


SURGERY.  647 

<ietails  have  been  observed  an  incision  about  3  inches  in 
length  is  made  along  the  outer  margin  of  the  erector  spinae 
extending  downward  from  the  last  rib.  The  underlying 
muscles  should  be  separated  rather  than  cut  and  care  should 
be  taken  to  avoid  injury  to  the  last  dorsal,  the  iliohypogastric 
and  the  ilio-inguinal  nerves.  After  separating  the  muscles 
and  dividing  a  layer  of  fascia,  the  subjacent  perirenal  fat  is 
■exposed.  The  fatty  capsule  is  torn  through  at  the  upper 
and  inner  portion  of  the  wound  and  reflected  downward  and 
outward  so  that  it  will  finally  form  a  cushion  beneath  and  to 
the  outer  side  of  the  sutured  organ.  The  fatty  capsule 
should  be  removed  from  the  kidney  except  at  the  hilum  which 
should  not  be  disturbed  on  account  of  the  renal  vessels.  The 
kidney  is  delivered  through  the  incision  and  two  sutures  of 
silk,  Pagenstecher,  or  chromicized  gut  are  introduced  upon 
each  of  its  surfaces.  Each  suture  passes  through  the  kidney 
tissue  at  right  angles  to  the  framework  of  the  cortex;  it  is 
passed  in  a  triangular  fashion  so  as  to  leave  two  suture  bridges 
on  the  surface  of  the  kidney  (Brodel  suture).  The  kidney  is 
now  replaced  without  twisting  of  the  structures  at  the  hilum. 
It  is  well  to  lessen  intra-abdominal  tension  at  this  stage  of 
the  operation  by  allowing  some  air  to  "escape  from  the 
Edebohl's  air  cushion.  The  ends  of  the  kidney  sutures  are 
now  passed  through  either  side  of  the  wound,  the  upper  pair 
being  as  close  to  the  last  rib  as  possible,  and  their  ends  tied 
so  that  the  knots  are  just  outside  of  the  deep  fsiscia.  The 
remaining  gaps  between  the  lumbar  muscles  are  closed  by  in- 
terrupted sutures  of  chromicized  catgut.  The  suture  imme- 
diately below  the  lower  pole  of  the  kidney  is  made  to  in- 
clude a  cushion-like  pad  of  the  perirenal  fat.  Hemostasis 
should  be  accurate  and  the  fixation  sutures  should  not  con- 
strict the  iliohypogastric  or  ilio-inguinal  nerves.  The  skin 
is  finally  united  with  an  intracuticular  catgut  suture. 

What  are   the   general   principles   governing:  the   treat- 
ment of  fractures  at  or  near  the  joints? 

Early  and  accurate  reduction.     Maintenance  of  reduction. 


648  SURGERY. 

Early  but  judicious  passive  motion.  While  trying  to  secure 
as  perfect  an  anatomic  result  as  possible  remember  that  the 
functional  result  is  of  first  importance. 

Describe  the  operation  of  trephining  the  skull. 

After  all  aseptic  details  have  been  observed  a  skin  flap  is 
made  with  the  base  downward.  The  pericranium  is  cleared 
from  the  bone  and  a  beveled  trephine  is  applied  with  the 
central  pin  projecting.  As  soon  as  a  well  defined  groove  has 
been  cut  the  pin  should  be  withdrawn.  When  the  diploe  has 
been  reached  the  trephine  will  work  more  easily  and  with  a 
softer  sound  and  there  will  be  an  increased  flow  of  blood.  This 
hemorrhage  should  warn  the  operator  to  proceed  slowly  since 
the  only  thing  between  the  trephine  and  the  dura  mater  is  the 
thin  vitreous  table.  The  groove  should  be  carefully  examined 
from  time  to  time  with  a  flat  probe  and  the  rotary  motion  of 
the  trephine  continued  until  three  or  four  penetrations  have 
been  made  when  the  button  of  bone  can  be  raised  with  an 
elevator.  The  greatest  care  should  be  exercised  to  avoid  in- 
jury to  the  dura.  If  there  is  undue  hemorrhage  from  the 
bone,  it  may  be  controlled  by  rubbing  in  Horsley's  wax, 
(phenol,  one  part;  oil,  two  parts;  wax,  seven  parts). 

What  are  the  indications  of  intestinal  perforation  in 
typhoid  fever  and  what  is  the  surgical  treatment? 

During  the  third  week  there  is  noticeable  a  sudden  change 
in  the  condition  of  the  patient.  This  is  ushered  in  by  severe 
abdominal  pain  of  increasing  severity  which  is  often  paroxy- 
smal in  character  and  usually  located  in  the  right  iliac  region. 
It  is  associated  with  muscular  rigidity  and  signs  of  shock, — 
a  fall  in  the  temperature,  an  increased  respiratory  and  pulse 
rate.  Tenderness  is  usually  present.  The  local  features  on 
palpation  are  much  more  marked  when  the  perforation  is 
in  contact  with  the  parietal  peritoneum  (Le  Conte).  Early 
irritability  of  the  bladder  with  frequent  micturition  is  some- 
times observed. 

The  surgical  treatment  consists  of  an  immediate  laparotomy 


SURGERY.  649 

and  closure  of  the  perforation  by  suture.  The  lower  ileum 
should  be  inspected  as  thoroughly  as  the  condition  of  the 
patient  will  warrant  and  points  suggestive  of  subsequent  per- 
foration reinforced  by  a  few  Lembert  sutures.  The  ab- 
dominal cavity  should  be  drained  and  the  Murphy  treatment 
for  peritonitis  at  once  instituted. 

Describe  in  detail  the  operation  for  lumbar  puncture  and 
name  the  conditions  in  which  it  may  be  employed. 

The  skin  over  the  lumbar  vertebrae  should  be  carefully 
disinfected.  With  the  patient  in  the  sitting  posture  the 
spinous  process  of  the  fourth  lumbar  vertebra  is  located  by 
a  line  joining  the  iliac  crests.  The  patient  now  leans  for- 
ward increasing  the  intervertebral  spaces  and  the  needle  is 
inserted  in  the  fourth  or  third  interspace  one-third  of  an  inch 
to  the  right  or  left  of  the  median  line.  If  introduced  in  the 
median  line  the  needle  should  be  pushed  slightly  upward; 
if  one-third  of  an  inch  to  either  side,  slightly  upward  and 
inward.  A  properly  beveled  irido-platinum  needle  should 
be  employed.  All  aseptic  details  should  be  observed  and  upon 
the  withdrawal  of  the  needle  the  small  punctured  wound 
immediately  sealed  ^vith  a  collodion  dressing. 

Tiumbar  puncture  is  employed  for  the  purpose  of  with- 
drawing cerebro-spinal  fluid.  This  may  be  done  for  diagnostic 
puiTDOses,  as  a  therapeutic  measure,  or  as  a  preliminary  step 
in  the  production  of  spinal  anesthesia. 

Describe  the  surgical  care  and  treatment  of  any  one 
form  of  gangrene. 

Senile  gangrene.  Shave  the  entire  lower  extremity  and 
thoroughly  disinfect  it  first  by  mechanical  and  then  by  chemi- 
cal means.  Wrap  it  up  in  aseptic  wool,  apply  external  heat, 
and  place  it  in  a  position  to  favor  its  circulation.  If  a  line  of 
demarcation  forms  in  the  foot  and  the  leg  seems  to  be  fairly 
well  nourished,  the  amputation  may  be  performed  in  the  leg. 
If  the  gangrenous  proce.ss  passes  the  ankle-joint  or  if  the 
log  bo  shriveled,  the  amputation  should  bo  made  tliroiigli  the 


€50  SURGERY. 

lower  third  of  the  thigh.  Always  operate  at  a  level  where 
a  relatively  healthy  artery  may  be  secured.  The  anesthetic 
should  be  chosen  with  great  care  and  the  operation  performed 
as  quickly  as  is  consistent  with  good  work. 

Name  the  symptoms  and  outline  the  surgical  treatment 
for  acute  intestinal  obstruction. 

Sudden  abdominal  pain  which  at  first  may  be  referred  to 
the  umbilicus.  Persistent  vomiting,  first  gastric  then  bilious 
and  finally  stercoraceous.  Absolute  constipation,  no  flatus 
being  passed;  occasionally  however,  the  lower  bowel  may 
empty  itself.  The  abdomen  soon  becomes  distended  and  ten- 
der. If  the  patient  reacts  from  shock,  there  may  be  some  rise 
of  temperature  but  unless  relief  be  obtained,  the  temperature 
^becomes  subnormal  and  the  pulse  rapid  and  feeble.  But  little 
urine  is  passed.  The  mind  is  clear,  the  tongue  is  dry,  and 
intestinal  peristalsis  above  the  obstruction  may  be  observed. 
Fecal  vomiting  can  not  occur  if  the  obstruction  is  in  the  upper 
third  of  the  ileum  nor  is  tympanites  apt  to  be  present  if  the 
trouble  is  high  up  in  the  small  intestine.  According  to  Blood- 
good  there  is  a  leukocytosis  of  from  15,000  to  30,000. 

Treatment.  As  soon  as  the  diagnosis  is  made  or  acute 
obstruction  can  not  be  positively  excluded,  wash  out  the 
stomach  and  empty  the  lower  bowel  by  copious  enemata.  If 
the  cause  be  an  external  hernia,  a  herniotomy  should  be  done ; 
in  other  cases  an  immediate  laparatomy  should  be  performed 
and  the  cause  of  the  obstruction  removed.  In  desperate 
cases  it  is  wise  to  do  a  palliative  operation, — enterostomy 
above  the  obstruction  and  then  wait  until  the  patient  is 
better  able  to  withstand  an  operative  procedure  which  may 
be  prolonged  and  associated  with  great  shock. 

Give  the  symptoms  and  treatment  of  acute  ischiorectal 
abscess. 

A  red  painful  swelling  at  one  side  of  the  anus,  which  is  at 
first  hard  and  brawny  but  which  soon  softens  and  fluctuates. 
The  patient  cannot  sit  comfortably,  defecation  is  painful  as  is 


SURGERY.  651 

also  digital  examination.  These  local  symptoms  are  -usually 
associated  with  a  feeling  of  chilliness  or  a  distinct  rigor  and 
fever. 

Treatment.  Do  not  wait  for  fluctuation  but  incise  freely 
the  moment  an  indurated  area  is  detected.  Free  drainage 
must  be  maintained  and  the  wound  made  to  heal  from  the 
bottom.  If  the  case  is  not  seen  until  late  it  is  extremely  likely 
that  the  pus  has  already  made  its  way  into  the  rectum  and 
the  resulting  fistula  must  not  be  overlooked. 

Describe  in  detail  intubation  of  the  larynx  and  state  the 
conditions  for  which  it  may  be  performed. 

The  instruments  needed  are  a  self-retaining  mouth-gag,  an 
intubation  tube  of  appropriate  size  with  its  obturator,  an 
instrument  for  the  introduction  of  the  tube,  which  is  screwed 
into  the  obturator  (the  introductor),  and  an  instrument  for 
the  extraction  of  the  tube  (the  extractor).  A  strand  of  silk 
should  be  passed  through  the  hole  in  the  collar  of  the  tube 
and  made  into  a  loop. 

The  child  with  the  arms  at  the  side  should  be  wrapped  in  a 
blanket.  An  assistant  holds  the  child  in  his  lap  with  the  legs 
between  his  knees  and  the  arms  held  at  the  elbows  so  as  not 
to  impede  the  respiratory  movements.  A  second  assistant 
holds  the  child's  head  exactly  in  the  median  line.  The  mouth 
gag  is  inserted  upon  the  right  side.  The  operator  sits  on  a 
chair  facing  the  patient.  He  passes  his  left  index  finger  over 
the  tongue  and  hooks  the  epiglottis  forward.  The  introduc- 
tor and  tube  are  now  passed  into  the  mouth,  care  being  taken 
that  the  silken  loop  is  free,  and  the  left  index-finger  is  moved 
slightly  to  the  left.  The  tube  is  now  passed  into  the  larynx, 
hold  in  place  by  the  left  index  finger,  and  the  obturator 
detached  by  pulling  upon  the  trigger.  The  tube  should  be 
pushed  down  by  the  left  index  finger  and  the  posterior  laryn- 
geal wall  palpated  to  be  sure  that  the  tube  is  in  the  proper 
place.  The  silken  loop  should  be  secured  to  the  cheek  by 
adhesive  plaster  for  several  hours  when  it  may  be  removed. 
If  the  intubation  be  done  for  diphtheria  the  danger  of  pushing 


652  SURGERY. 

the  false  membrane  down  ahead  of  the  tube  should  be  borne  in 
mind.  Tracheotomy  instruments  should  always  be  at  hand 
and  the  parents'  consent  for  this  operation  previously  ob- 
tained. 

Intubation  may  be  performed  for  laryngeal  stenosis  which 
may  be  due  to  diphtheria,  the  presence  of  a  foreign  body, 
syphilis,  cicatrization,  or  malignant  growths.  It  may  also  be 
done  as  a  preliminary  to  Fell's  method  of  forced  artificial 
respiration. 

Give  the  mechanical  and  the  operative  treatment  of  in= 
fantile  paralysis  (acute  anterior  poliomyelitis)  when  the 
legs  are  involved. 

Mechanical  support  should  be  judiciously  applied  in  such 
a  way  that  the  movements  are  not  hampered  by  unnecessary 
weight.  In  paralytic  talipes  the  braces  should  fix  the  knees 
and  it  is  frequently  necessary  to  have  them  extend  up  to  the 
pelvis. 

The  operative  treatment  consists  of  the  performance  of 
tenotomy,  tenoplasty,  arthrodesis  or  (in  some  cases)  ampu- 
tation. 


OBSTETRICS  AND  GYNECOLOGY. 


Describe  the  female  reproductive  organs. 

The  ovaries  are  two  small  almond-shaped  organs  situated 
one  on  either  side  of  the  uterus  (described  below)  and  at- 
tached to  the  posterior  surface  of  the  broad  ligaments.  Each 
is  4  cm.  long,  2  cm.  broad  and  li/o  cm.  thick,  and  weighs  6.4 
gm.  (100  grains).  It  consists  of  the  oophoron  or  egg-bearing 
portion  and  the  paroophoron  or  fibrous  portion. 

The  oviducts  or  Fallopian  tubes  are  the  trumpet-shaped 
structures  attached  to  the  uterine  cornua.  Each  tube  is  about 
111/2  cm.  long,  and  surrounds  the  corresponding  ovary.  The 
outer  end  is  the  fimbi'iated  extremity.  The  tube  is  lined  with 
ciliated  epithelium,  which  facilitates  the  passage  of  the  ovum 
to  the  uterus. 

The  vagina  or  organ  of  copulation  is  the  passage  from  the 
vestibule  to  the  cervix.  It  lies  at  an  angle  of  60°  to  the  hori- 
zon. It  has  two  walls,  anterior  and  posterior.  Its  mucous 
membrane  lies  in  folds  or  rugae. 

The  hymen  is  the  fold  of  vaginal  mucous  membrane  guard- 
ing the  lower  orifice  of  the  vagina. 

The  vidva  or  external  genitals  includes  the  labia  majora, 
labia  minora,  clitoris,  vestibule  and  mons  veneris.  The  labia 
majora  are  the  fleshy  folds  on  either  side  of  the  vestibule; 
the  labia  minora  or  nymphae  are  the  two  small  mucous  folds 
situated  within  the  greater  lips;  they  unite  above  to  form 
the  prepuce  of  the  clitoris.  The  latter  is  the  analogue  of  the 
penis.  The  vestibule  is  the  triangular  space  bounded  above 
by  the  clitoris,  laterally  by  the  labia  minora,  and  below  by  the 
orifice  of  the  vagina.  The  mons  veneris  is  the  fleshy  eminence 
above  the  symphysis  pubis. 

(653) 


654  OBSTETRICS  AND  GYNECOLOGY. 

Give  a  description  of  the  physiology  of  menstruation. 

Menstruation  is  a  periodic  series  of  phenomena  occurring 
normally  every  28  days  in  the  non-pregnant  female  from 
puberty  to  the  menopause,  consisting  of  certain  symptoms 
(menstrual  molimina)  and  a  characteristic  sero-sanguinolent 
discharge  derived  from  the  congested  mucosae  of  the  tubes 
and  uterus.  The  process  consists  in  a  growth  of  the  stroma 
of  the  uterine  mucosa  and  a  breaking-down  of  the  congested 
vessels,  with  consequent  formation  of  lacunae,  which  rupture. 

What  is  the  duration  of  menstruation  and  what  are  the 
resulting  changes  in  the  uterine  mucous  membrane? 

Menstruation  normally  lasts  3  to  4  days.  It  is  accom- 
panied by  a  growth  in  the  stroma  of  the  uterine  mucosa,  or 
congestion  of  the  vessels  which  rupture,  and  subsequent 
degeneration  of  the  superficial  layers  of  the  mucosa. 

What  is  vicarious  menstruation? 

A  periodic  discharge  of  blood  or  other  fluid  from  the  nose, 
breast,  stomach,  or  other  organ  during  a  period  of  suppressed 
menstruation. 

What  are  the  abnormalities  of  menstruation  and  give 
their  etiology  and  treatment. 

The  abnormalities  of  menstruation  are :  Amenorrhea,  or 
absence  of  the  menstrual  fluid ;  scanty  menstruation,  or  insuffi- 
cient flow;  menorrhagia,  or  excessive  flow  at  the  menstrual 
periods;  metrorrhagia,  or  a  flow  between  the  periods;  and 
dysmenorrhea,  or  painful  menstruation.  Amenorrhea  results, 
from  anemia,  chlorosis,  phthisis,  nervous  and  mental  dis- 
eases, change  of  climate,  and  uterine  and  ovarian  defects  of 
development.  It  is  treated  by  diet,  exercise,  iron,  tonics, 
arsenic,  and  the  so-called  emmenagogues.  Menorrhagia  and 
metrorrhagia  result  from  endometritis,  tumors,  salpingitis 
and  other  causes  of  pelvic  congestion,  including  subinvolu- 
tion after  labor.  They  may  be  treated  by  astringents  inter- 
nally, as  hydrastis,  ergot,  oil  of  erigeron,  thyroid  extract,  and 
mammary  extract,  or  by  local  treatment,  including  curettage.. 


OBSTETRICS  AND  GYNECOLOGY.  655 

Dysmenorrhea  requires  dilatation  and   curettement  and  re- 
placement of  displaced  organs. 

What  conditions  have  a  bearing  on  the  time  of  life  in 
the  female  when  menstruation  first  occurs? 

Race,  social  development,  climatic  influences  and  predis- 
position. The  average  age  of  puberty  in  this  country  is  about 
the  fourteenth  year. 

What  is  the  placenta?  From  what  is  it  formed,  what 
is  its  structure,  and  what  are  its  functions? 

The  placenta  is  the  essential  nutritive  and  respiratory  organ 
of  the  fetus.  It  is  formed  from  the  chorion  frondosum  and 
the  deeidua  serotina,  and  assumes  its  functions  by  the  end  of 
the  third  month. 

Describe  the  development  of  the  placenta. 

During  the  rapid  development  of  the  chorion  frondosum, 
or  hairy  chorion,  a  corresponding  change  takes  place  in  the 
decidua-serotina ;  its  tissues  hypertrophy  and  become  thick, 
spongy  and  very  vascular.  The  chorionic  villi  sink  deeply 
into  this  pulpy  mass  and  become  intimately  connected  with  it, 
permitting  of  osmosis  or  interchange  of  the  maternal  and 
embryonic  blood.  By  the  third  month  these  structures  have 
developed  into  the  fully  formed  placenta. 

What  are  the  functions  of  the  placenta? 

1.  The  supplying  of  nourishment  from  the  mother  to  the 
fetus.  2.  The  oxygenation  of  the  impure  fetal  blood.  3. 
The  excretion  of  the  effete  products  from  the  fetus. 

Describe  the  human  uterus  and  give  its  anatomic 
relations. 

The  uterus  is  a  hollow  muscular  organ  situated  in  the  cen- 
ter of  the  pelvis  and  embraced  between  the  folds  of  the  broad 
ligaments.  It  is  7%  cm.  long,  4  cm.  broad,  and  2%  cm.  thick; 
it  weighs  31  grams  (7  drams).  The  upper  portion  above  the 
point  of  entrance  of  the  Fallopian  tubes  is  the  fundus,  the 
portion  between  the  tubes  and  the  internal  os  is  the  body 


656  OBSTETRICS  AND  GYNECOLOGY. 

proper,  and  that  between  the  internal  and  external  os  is  the 
cervix.  The  flattened  anterior  surface  is  in  close  juxtaposi- 
tion with  the  bladder ;  the  posterior  surface  is  separated  from 
the  rectum  by  Douglas'  pouch  or  cul-de-sac.  The  cavity  of 
the  uterus  measures  614  cm.  (21/^  in.). 

How  is  the  uterus  supplied  with  nerves? 

The  uterus  is  supplied  by  filaments  from  the  hypogastric 
and  ovarian  plexuses  of  the  sympathetic  nervous  system. 

Describe  the  normal  non=gravid  uterus,  giving  its  func= 
tions  and  relation  to  the  other  organs  of  generation. 

The  uterus  has  already  been  described.  It  lies  above  the 
vagina,  its  axis  being  at  right  angles  to  the  axis  of  the  vagina. 
The  tubes  are  continuous  with  the  cornua,  and  extend  one  to 
either  side  of  the  fundus.  The  ovaries  are  on  either  side  of 
the  uterus  below  the  tubes. 

Describe  the  semen. 

The  semen  is  a  thick,  viscid,  yellowish  or  opalescent  fluid, 
with  a  faint  characteristic  lime-like  odor,  secreted  by  the  tes- 
ticles and  prostate  gland.  Its  most  important  constituents 
are  the  spermatozoids. 

Define  insemination  and  state  the  conditions  necessary 
to  its  accomplishment. 

Insemination  is  the  deposit  of  the  semen  within  the  vagina 
during  copulation.  It  is  not  necessarily  followed  by  impreg- 
nation. 

What  are  spermatozoa?  Where  are  they  found?  De- 
scribe their  appearance  and  function. 

The  spermatozoa  are  microscopic,  tadpole-like  bodies  pres- 
ent in  immense  numbers  in  the  semen.  They  are  about  1-500 
of  an  inch  in  length,  and  are  derived  from  the  sperm-cells  of 
the  seminal  tubules  of  the  testicles.  They  have  flat,  oval 
heads,  small  bodies  ,and  immensely  elongated  flagella  or  tails, 
which  are  in  constant  motion.  Their  function  is  fertilization 
of  the  ovum. 


OBSTETRICS  AND  GYNECOLOGY.  657 

Give  the  definition,  physiology  and  frequency  of  ovula- 
tion and  state  whether  ovulation  and  menstruation  are 
synchronous. 

Ovulation  is  the  formation,  development  and  discharge  of 
a  mature  ovum  from  the  ovary.  It  occurs  once  or  twice  in 
a  month,  and  is  not  necessarily  synchronous  with  menstru- 
ation. 

What  is  the  mechanism  of  the  escape  of  the  ovule  and 
its  transmission  to  the  tubes  and  uterus? 

Upon  the  establishment  of  puberty  certain  Graafian  folli- 
■cles  assume  extraordinary  growth,  and  rapidly  approach  the 
ovarian  surface.  Owing  to  the  increased  intrafollicular  pres- 
sure the  capsule  yields  and  the  contents — an  ovum  and  the 
liquor  folliculi — escape.  The  ovum  is  received  into  the  Fal- 
lopian tube  either  by  direct  introduction  at  the  time  of  rupture 
or  by  suction,  and  is  then  carried  into  the  uterine  cavity  by 
the  action  of  the  ciliated  epithelium  of  the  tube. 

Define  fecundation  and  describe  its  physiology. 

Fecundation  is  the  fertilization  of  the  ovum  by  the  sper- 
matozoids.  It  is  accomplished  according  to  some  in  the  tubes 
or  on  the  ovarian  surface,  and  according  to  others  in  the 
uterine  fundus.  The  spermatozoids  penetrate  the  vitelline 
membrane  of  the  ovum  through  the  micropyle.  The  ovum 
then  undergoes  a  series  of  progressive  changes. 

Give  the  successive  changes  that  take  place  in  the  ovum 
after  fecundation,  and  during  its  passage  to  the  uterus. 

1.  Absorption  of  the  vibratile  extremity  of  the  spernuito- 
zoid,  leaving  the  head  only,  which  is  known  as  the  male  pro- 
nucleus. 2.  Union  of  the  male  and  female  pronuclei  to  form 
the  oosperm  or  blastosphere.  3.  Divisions  of  the  vitelline  nu- 
•cleus,  followed  by  segmentation  of  the  vitellus,  resulting  in 
the  formation  of  the  moruln  or  mulberry  mass.  4,  Appear- 
ance in  the  center  of  the  morula  of  a  transparent  fluid,  which 
conden.ses  the  morula  into  a  thin  cellular  layer  {blastoderm 
■or  blastodermic  membrane) .  5.  Division  of  the  blastoderm 
42 


658  OBSTETRICS  AND  GYNECOLOGY. 

into  the  epihlast,  mesohlast  and  hypoMast.     6.  Aggregation 
of  the  hypoblastic  cells  into  the  germinal  or  emhryonic  area. 

7.  Appearance  in  this  of  the  primitive  trace  or  embryonic 
line,  surrounded  by  a  translucent  space,  the  area  pellucida. 

8.  Incurving  of  the  extremities  of  the  primitive  trace  to  form 
the  fetal  ellipse.     9.  Development  of  the  embryonal  parts. 

Describe  the  vitellus,  the  allantois,  and  the  amnion. 

The  vitellus  is  the  protoplasmic  yelk  of  the  ovum.  The 
allantois  is  a  small  pear-shaped  vesicular  structure  which 
develops  from  the  lower  portion  of  the  embryonic  alimentary 
canal  at  about  the  20th  day  of  intra-uterine  life.  It  is  a  vas- 
cular structure,  and  is  the  forerunner  of  the  placenta.  It  is 
intimately  associated  with  the  chorion.  The  amnion  is  a 
smooth,  tough,  transparent,  glistening,  fibrous  structure,  the 
innermost  of  the  fetal  membranes,  surrounding  the  fetus  and 
continuous  with  it  at  the  umbilicus;  it  secretes  and  encloses, 
the  liquor  amnii. 

Describe  the  fully  developed  ovum. 

The  ovum  is  the  vital  element  or  reproductive  cell  of  the 
female.  It  varies  in  size  from  1-500  to  1-120  of  an  inch.  It 
consists  of  a  protoplasmic  yelk  or  vitellus  and  a  nucleus  or 
germinal  vesicle  (vesicula  germinativa)  enclosed  within  a 
hyaline  covering,  the  zona  pellucida  or  vitelline  membrane. 

What  is  the  character  of  the  liquor  amnii  and  what  are 
its  sources  and  uses? 

The  liquor  amnii  is  an  algaline  fluid,  about  a  quart  in 
quantity,  with  a  light  specific  gravity,  an  opaque  white  color, 
and  a  characteristic  odor.  It  prevents  undue  pressure  of  the 
uterine  walls  upon  the  fetus,  it  saves  the  uterus  from  injury 
due  to  the  fetal  movements,  it  maintains  an  equable  temper- 
ature around  the  fetus,  and  it  receives  and  dilutes  the  excre- 
tions of  the  fetus.  It  is  derived  from  the  fetus  largely,  and 
•contains  much  fetal  urine. 

What  is  the  umbilical  cord  and  how  is  it  formed? 

The  funis  or  umbilical  cord  is  a  cord-like  structure  extend- 


OBSTETRICS  AND  GYNECOLOGY.  659 

ing  from  the  umbilicus  of  the  fetus  to  the  placenta.  It  is 
developed  from  the  pedicle  of  the  allantois  at  about  the  fourth 
week  of  pregnancy.  It  measures  at  term  about  50  cm.  in 
length. 

What  structures  compose  the  fully  developed  umbilical 
cord? 

Two  umbilical  arteries,  one  umbilical  vein,  the  vitelline 
duct,  the  pedicle  of  the  allantois,  and  the  jelly  of  Wharton. 

What  are  uterine  hydatids  (hydatid  pregnancy)?  What 
are  their  source  and  treatment? 

This  is  an  unusual  name  for  hydatidiform  mole  or  cystic 
disease  of  the  chorion,  a  rare  affection  of  the  chorion  consist- 
ing in  a  proliferative  degeneration  of  the  chorionic  villi  with 
the  production  of  a  mass  of  grape-like  vesicles  attached  to  the 
placenta.  The  disease  occurs  about  once  in  2000  cases  of 
pregnancy.  The  treatment  consists  in  immediate  evacuation 
of  the  uterine  contents. 

What  changes  take  place  in  the  female  at  puberty? 

Hair  appears  above  the  pubis;  the  breasts  develop;  the 
function  of  ovulation  is  established;  menstruation  appeal's; 
the  pelvis  widens;  and  there  is  a  growth  of  the  sexual  sense. 

What  are  the  differences  between  the  male  pelvis  and 
the  female  pelvis?  Give  the  importance  of  the  female 
characteristics  in  labor. 

Male.  Heavy  structure.  Cavity  deep  and  contracted. 
Sacrum  narrow  and  slightly  curved.  Ischial  tuberosities 
closely  approximated.  Subpubic  angle  75°-80°.  Pelvic  brim 
triangular.  Slight  pelvic  inclination.  Thyroid  foramen 
oval. 

Female.  Light  structure.  Cavity  shallow  but  roomy. 
Sacrum  wide  and  deeply  curved.  Ischial  tuberosities  widely 
separated.  Subpubic  angle  90°-100°.  Pelvic  brim  cordate. 
Great  pelvic  inclination.     Thyroid  foramen  triangular. 

The  female  characteristics  favor  ready  transit  of  a  fetus 
through  the  pelvis. 


660  OBSTETRICS  AND  GYNECOLOGY. 

Give  the  bones,  divisions,  straits  and  symphyses  of  the 
obstetric  pelvis. 

The  pelvis  is  composed  of  the  two  innominate  bones,  the 
sacrum  and  the  coccyx ;  it  is  divided  into  the  true  pelvis  below 
and  the  false  pelvis  above  the  iliopectineal  line.  This  line 
forms  the  boundary  of  the  inlet  or  superior  trait.  The  lower 
orifice  is  the  inferior  strait.  The  symphyses  are  three  in  num- 
ber, viz.,  the  pubic,  and  the  two  sacro-iliac  synchondroses. 

Give  the  obstetric  landmarks  of  the  superior  and  infe- 
rior straits. 

Superior  strait.  The  four  cardinal  points,  viz.,  the  sacro- 
iliac synchondroses,  and  the  iliopectineal  eminences;  also  the 
promontory  of  the  sacrum,  and  the  iliopectineal  line.  I7ife- 
rior  strait.  The  tips  of  the  coccyx,  the  ischial  tuberosities, 
and  the  subpubic  angle. 

Give  the  names  and  dimensions  of  the  diameters  of  the 
pelvic  inlet. 

The  conjugate  or  anteroposterior,  11  cm. ;  the  trainsverse, 
131/^  cm.,  and  the  two  oblique  diameters  (between  one  ilio- 
pectineal eminence  and  the  opposite  sacro-iliac  synchon- 
drosis), 12%  em. 

What  are  the  diameters  of  the  pelvic  outlet?  How  is 
the  pelvic  outlet  bounded? 

The  transverse  (between  the  ischial  tuberosities)  11  cm., 
and  the  conjugate  (between  the  tip  of  the  coccyx  and  the  sub- 
pubic ligament)  9i/4  cm.  at  rest,  and  11  cm.  in  labor.  The 
pelvic  outlet  is  bounded  by  the  tip  of  the  coccyx,  the  ischial 
tuberosities,  the  sacrosciatic  ligaments,  the  thyroid  foramina, 
and  the  subpubic  ligament. 

Differentiate  the  planes  and  axes  of  the  pelvis  and  men- 
tion their  obstetric  importance. 

The  plane  of  the  superior  strait  forms  an  angle  of  50°-60° 
with  the  horizon ;  the  plane  of  the  inferior  strait  forms  a  line 
of  10'^  with  the  horizon.     The  roomiest  portion  of  the  pelvic 


OBSTETRICS  AND  GYNECOLOGY.  661 

cavjty  forms  what  is  known  as  the  plane  of  pelvic  expansion, 
while  the  narrowest  portion  of  the  cavity  forms  the  plane  of 
pelvic  contraction.  The  axis  of  the  pelvic  cavity,  known  as 
the  curve  of  Cams,  extends  from  the  middle  of  the  plane  of 
the  superior  strait  to  the  middle  of  the  plane  of  the  inferior 
strait,  and  follows  the  curve  of  the  sacrum.  The  greater  its 
curvature,  the  more  difficult  the  labor;  also  the  greater  the 
pelvic  obliquity,  the  more  difficult  the  labor. 

What  are  the  varieties  of  deformed  pelvis? 

The  most  commonly  recognized  varieties  are  the  simple 
flat,  the  spondylelisthetic,  the  rachitic,  the  coxalgie,  the  sco- 
liotic, the  osteomalacic,  Naegele's,  Robert's,  the  kyphotic,  the 
kyphoseoliotie,  the  justo-minor,  the  generally  contracted  and 
flat,  the  justo-major,  the  split  pelvis,  and  the  pelves  distorted 
by  tumors  and  fractures. 

What  difficulties  arise  during  labor  from  malformations 
of  the  maternal  pelvis? 

If  the  pelvis  be  increased  in  size  a  precipitate  labor  will 
probably  result.  If  it  be  contracted  there  will  occur  all  de- 
grees of  obstruction,  from  the  slightest  retardation  to  total 
blocking  of  the  fetal  progress.  This  will  result  in  increased 
severity  of  the  labor  pains,  rise  of  the  contraction-ring,  early 
escape  of  the  liquor  amnii,  serious  compression  of  the  fetal 
head,  malpositions  and  the  malpresentations  of  the  fetus,  and 
sloughing  of  the  maternal  soft  parts. 

What  varieties  of  deformed  pelvis  are  liable  to  inter= 
fere  with  obstetric  procedures?     How? 

All  pelves  that  are  contracted  in  the  superior  or  inferior 
straits  will  more  or  less  seriously  obstruct  labor.  This  in- 
cludes the  vast  majority  of  deformed  pelves,  whatever  the 
cause  of  the  deformity. 

Describe  and  differentiate  justo-minor  pelvis  and  justo- 
major  pelvis,  and  state  how  each  may  complicate  labor. 

The  justo-minor  pelvis  is  one  equally  contracted  in  all  of 


662  OBSTETRICS  AND  GYNECOLOGY. 

its  diameters;  it  is  normal  in  shape,  but  undersized.  The 
justo-major  pelvis  is  one  equally  enlarged  in  all  its  diameters. 
The  former  obstructs  labor;  the  latter  predisposes  to  precipi- 
tate labor. 

Describe  a  non=rachitic  flat  pelvis,  and  give  the  man^ 
agement  of  labor  in  such  a  condition. 

This  is  a  very  common  form  of  pelvic  deformity,  consisting 
in  a  diminution  in  the  anteroposterior  diameter  of  the  supe- 
rior strait  of  the  pelvis  without  any  disturbance  in  the  size  of 
the  other  diameters.  As  a  rule,  it  does  not  result  in  serious 
interference  of  labor,  although  instrumental  delivery  may  be 
required. 

What  structures  enter  into  the  formation  of  the  pelvic 
floor? 

From  without  inward  the  muscles  of  the  pelvic  floor  are  the 
transversus  peronei,  the  ischiocavernosus,  the  sphincter  ani, 
the  sphincter  vaginae,  the  coccygeus,  and  the  levator  ani  mus- 
cles, together  with  the  pelvic  fascia  and  the  perineal  wedge 
or  body. 

What  changes  occur  in  the  uterus  during  pregnancy? 

There  is  a  general  hypertrophy  of  all  the  uterine  tissues, 
especially  of  the  muscular  substances.  The  blood-vessels  are 
increased  in  number,  size,  length  and  tortuosity.  The  veins 
lose  all  their  coats  but  the  intima.  The  uterus  slightly  ro- 
tates on  its  axis  from  left  to  right  during  its  development. 

What  are  the  effects  of  pregnancy  on  the  maternal 
organisms? 

In  addition  to  the  uterine  changes  already  described  there 
will  be  noted  the  following :  A  deposit  of  fat  in  the  abdominal 
wall,  an  edema  of  the  joints  of  the  pelvis,  congestion  of  the 
pelvic  viscera,  an  increase  in  the  quantity  of  blood  and  of  the 
urine,  alterations  in  taste  and  disposition,  and  a  softening  of 
the  bones  of  the  entire  body. 


OBSTETRICS  AND  GYNECOLOGY.  663 

What  changes  occur  during  pregnancy  in  the  external 
genitals  and  vagina? 

There  will  be  noted  an  increased  vascularity,  with  edema 
and  softening  of  the  tissues,  and  bluing  of  the  mucous  mem- 
brane. 

What  changes  occur  in  the  breasts  during  pregnancy? 

The  breasts  become  enlarged  generally  and  much  engorged, 
and  a  deposit  of  pigment  takes  place  in  the  areola.  This  pri- 
mary ring  of  pigment  may  be  surrounded  by  a  secondary 
areola  of  light  color.  The  glands  of  Montgomery  become 
enlarged  and  protuberant.  The  nipples  become  prominent, 
and  colostrum  develops  in  the  mammary  glands. 

What  changes  occur  in  the  blood  during  gestation? 

The  general  quantity  of  the  blood  is  increased,  while  its 
quality  decreases;  in  other  words,  there  exists  a  combined 
hydremia  and  anemia.  There  is  an  increased  tendency  to 
clot  from  the  large  amount  of  fibrinogen  present. 

Describe  the  human  embryo  during  the  second  month, 
during  the  fifth  month,  during  the  seventh  month,  and 
during  the  ninth  month,  giving  size  and  weight. 

At  the  second  month  the  embryo  is  the  size  of  a  pigeon's 
e^g ;  the  visceral  clefts  are  closed ;  the  head  forms  more  than 
two-thirds  of  the  embryo,  and  all  its  features  may  be  distin- 
guished; the  hands  and  feet  are  webbed;  the  length  of  the 
fetus  is  4  cm.  (II/2  inches)  ;  its  Aveight  is  4  grams  (60-62 
grains). 

At  the  fifth  month  the  face  is  wrinkled  and  senile,  the  hair 
and  nails  are  fully  formed,  the  vernix  caseosa  appears,  the 
eyelids  begin  to  open ;  the  umbilical  cord  is  about  12  inches 
long;  the  length  of  the  fetus  is  about  25  cm.  (9%  inches)  ; 
its  weight  273  grams  (10  8-10  ounces). 

At  the  seventh  month  the  skin  is  still  wrinkled  and  reddish, 
the  lanugo  begins  to  disappear  from  the  face,  the  eyelids  are 
open,  the  membrana  pupillaris  disappears;  the  length  of  tie 


664  OBSTETRICS  AND  GYNECOLOGY. 

fetus  is  35  cm.    (13%  inches)  ;  its  weight  1213  grains   (3^ 
ounces) . 

At  the  ninth  month  the  senile  appearance  of  the  face  dis- 
appears, the  lanugo  begins  to  disappear  from  the  body;  the 
length  of  the  fetus  is  45  cm.  (17%  inches)  ;  its  weight  1990 
grams  (5%  pounds). 

Name  the  diseases  of  the  fetus  and  its  membranes  in 
utero. 

The  fetus  may  suffer  from  various  infectious  diseases  trans- 
mitted to  it  through  the  placental  circulation;  rarely  it  may 
develop  tuberculosis  in  this  way;  fetal  rickets  is  a  common 
condition,  as  is  also  fetal  syphilis;  very  rarely  the  fetus  may 
develop  tumors  in  various  portions  of  the  body;  maternal 
impressions  may  be  noted;  and  various  intracranial  diseases, 
as  meningocele,  hydrocephalus  and  the  like;  fetal  ichthyosis 
is  rarely  noted.  The  diseases  of  the  membranes  include 
hydramnios,  oligohydramnios,  and  cystic  disease  of  the  cho- 
rion. 

How  would  you  diagnose  the  death  of  the  fetus  in  utero? 

In  about  the  order  of  value  the  signs  of  fetal  death  are :  1. 
Cessation  of  abdominal  and  uterine  growth,  followed  by  sub- 
sidence in  the  size  of  the  uterus.  2.  Subsidence  of  the  signs 
of  pregnancy.  3.  Absence  of  fetal  heart-sounds  and  fetal 
movements.  4.  Absence  of  pulsation  in  the  umbilical  cord  or 
fetal  preeordium.  5.  Decrease  in  the  cervical  temperature. 
6.  Appearance  of  milk  in  the  breasts  (occasional).  7.  Pep- 
tone or  acetone  in  the  urine.  8.  Cranial  crepitus  in  case  of 
maceration  of  the  fetus. 

How  may  death  of  the  fetus  in  utero  be  recognized  after 
the  period  of  viability?  What  should  be  done  in  such 
cases? 

Fetal  death  may  be  presupposed  by  a  suppression  of  all 
the  signs  of  pregnancy  that  have  been  present ;  by  absence 
of  the  fetal  heart-sounds;  by  cessation  of  the  growth  of  the 
abdomen,    with   subsequent   diminution   in   the   size   of   the 


OBSTETRICS  AND  GYNECOLOGY.  665 

abdominal  girth,  and  occasionally  by  the  appearance  of  milk 
in  the  breasts.  "When  fetal  death  is  assured  the  uterine  con- 
tents should  be  removed. 

Give  the  obstetric  anatomy  of  the  fetal  head. 

The  fetal  head  at  term  consists  of  the  two  frontal  bones, 
the  two  parietal  bones,  the  occiput  and  the  bones  of  the  face. 
These  various  bones  are  separated  by  sutures,  as  follows; 
The  frontal,  the  sagittal,  the  coronal,  the  lambdoid,  and  by 
the  two  fontanels,  the  anterior  and  the  posterior. 

Name  the  various  diameters  of  the  fetal  head. 

The  diameters  of  the  fetal  head  are  as  follows :  The  bitem- 
poral, 8  cm. ;  the  biparietal,  between  the  two  parietal  emi- 
nences, 91/4  cm. ;  the  bimastoid,  between  the  two  mastoid 
processes,  7%  cm.;  the  occipito-frontal,  from  the  root  of  the 
nose  to  the  external  occipital  protuberance.  11%  cm. ;  the 
occipito-mental,  from  the  point  of  the  chin  to  the  external 
occipital  protuberance,  131/2  cm. ;  the  suboceipito-bregmatic, 
from  the  central  point  of  the  bregma  to  a  point  midway  be- 
tween the  occipital  protuberance  and  the  foramen  magnum, 
9%  cm. ;  the  f rontomental,  from  the  top  of  the  forehead  to  the 
point  of  the  chin,  8  cm.;  the  trachelo-bregmatic,  from  the 
central  point  of  the  bregma  to  the  anterior  margin  of  the 
foramen  magnum,  91^  cm. ;  and  the  mento-bregmatic  or 
cervico-bregmatic,  from  the  central  point  of  the  bregma  to 
the  junction  of  the  chin  and  neck,  9i/4  cm. 

Describe  the  fontanels  and  their  diagnostic  uses. 

The  anterior  or  larger  fontanel  or  bregma  is  a  diamond- 
whaped  space  left  at  the  point  of  junction  of  the  frontal, 
coronal  and  sagittal  sutures.  The  posterior  or  smaller  fon- 
tanel is  situated  at  the  point  of  junction  of  the  lambdoid  and 
sagittal  sutures,  and  is  triangular  in  shape.  It  is  felt  in  all 
normal  vertex  presentations,  and  by  its  situation  determines 
the  position  of  the  head  in  labor.  The  bregma  is  never  felt 
in  a  normal  presentation,  but  may  be  palpated  in  the  presen- 
tation of  the  top  of  the  head,  in  a  brow  presentation,  and  in 
presentation  of  the  occiput  in  the  hollow  of  the  sacrum. 


666  OBSTETRICS  AND  GYNECOLOGY. 

What  is  meconium  and  what  are  its  diagnostic  relations? 

Mecomum  is  the  peculiar  o-reenish  substance  contained  in 
the  fetal  bowels  at  birth.  If  it  be  discharged  prior  to  the 
delivery  of  the  child,  it  generally  indicates  a  breech  pre- 
sentation. Occasionally  it  will  escape  in  difficult  head- 
deliveries. 

Describe  the  fetal  heart=sounds,  give  their  rate,  and 
state  when  and  where  they  are  best  heard. 

The  fetal  heart-sounds  constitute  an  absolute  sign  of  preg- 
nancy from  the  sixth  month  of  gestation  on.  They  resemble 
the  ticking  of  a  watch  under  a  pillow;  their  rate  is  about 
twice  that  of  the  maternal  heart-beat,  averaging  from  120  to 
160  beats  a  minute.  The  position  of  maximum  intensity 
varies  according  to  the  fetal  presentation.  In  anterior  ver- 
tex presentations  they  are  best  heard  at  a  point  midway  be- 
tween the  umbilicus  and  the  anterior  spinous  process  of  that 
side  upon  which  the  fetus  is  resting,  while  in  posterior  vertex 
presentations  the  point  of  maximum  intensity  would  be  in 
the  correspondng  flank,  slightly  below  a  transverse  line  pass- 
ing through  the  umbilicus. 

What  is  ballottement,  and  how  is  it  performed? 

Ballottement  is  a  balancing  of  the  fetus  in  utero  between 
the  fingers  of  the  two  hands.  In  vaginal  ballottement  the 
index  and  middle  fingers  of  the  left  hand  are  inserted  into  the 
anterior  vaginal  fornix,  the  patient  lying  in  the  dorsal  posi- 
tion, while  the  fundus  is  steadied  by  the  right  hand  placed 
upon  the  abdomen.  The  vaginal  fingers  give  a  sudden  im- 
pulse to  the  anterior  uterine  wall,  whereby  the  fetus  is  dis- 
placed upward ;  the  latter  gently  falls  back  and  strikes  upon 
the  propelling  fingers.  This  sign  is  positive,  and  is  available 
from  the  middle  of  the  fourth  to  the  eighth  months. 

How  would  you  diagnose  pregnancy  at  five  months,  at 
or  before  the  end  of  the  third  month,  and  at  full  term? 

In  the  first  three  months  of  pregnancy  the  following  signs 


OBSTETRICS  AND  GYNECOLOGY.  667 

are  present:  Menstrual  suppression,  nausea  and  vomiting, 
and  the  four  soft  signs,  viz.,  Goodell's  sign  (softened  cervix), 
Hegar's  sign  (softened  lower  uterine  segment),  the  soft  and 
boggy  uterine  body,  and  the  soft  and  enlarged  mammaB.  with 
the  darkened  areolas. 

At  the  fifth  month  there  will  be  added  to  the  foregoing 
Jacquemin's  sign  (the  bluing  of  the  vaginal  and  vulvar 
mucosa),  Braxton  Hicks'  intermittent  uterine  contraction, 
ballottement,  and  quickening;  the  uterus  will  also  be  con- 
siderably more  enlarged. 

At  tenn  all  the  foregoing  signs  are  present,  save  ballotte- 
ment, and  in  addition  the  fetal  heart-sounds  may  be  detected, 
and  palpation  will  reveal  the  fetal  outlines  both  above  and 
below. 

What  are  the  subjective  signs  of  pregnancy? 

The  subjective  signs  of  pregnancy  are  those  recognized  by 
the  patient  herself.  This  includes  menstrual  suppression, 
nausea  and  vomiting,  vesical  irritability,  quickening,  pain  in 
the  abdominal  walls  from  excessive  distension,  vertigo,  palpi- 
tation, and  gastric  disturbance. 

What  signs  of  pregnancy  are  determined  by  the  touch? 

The  four  "soft  signs,"  the  fetal  parts  and  presentation, 
ballottement,  Braxton  Hicks'  sign,  the  uterine  enlargement, 
and  the  fetal  movements. 

What  may  be  learned  by  abdominal  palpation  of  the 
pregnant  woman  after  the  eighth  month? 

The  fetal  movements,  the  fetal  parts,  the  position  and  pre- 
sentation of  the  fetus,  the  size  and  position  of  the  uterus,  the 
degree  of  distension  of  the  uterine  and  abdominal  walls,  the 
size  of  the  pelvic  inlet,  the  movability  of  the  fetal  head. 

Classify  the  objective  signs  of  pregnancy  and  state  their 
relative  value. 

The  five  positive  sights  of  pregnancy  are  ballottement,  fetal 
movements,  fetal  heart-sounds,  blue  discoloration  of  the  \iilva 


668  OBSTETRICS  AND  GYNECOLOGY. 

and  vagina,  and  intermittent  uterine  contractions.  Other 
valuable  objective  signs  are  cervical  softness  (in  primipara;), 
Hegar's  softening  of  the  lower  uterine  segment,  darkening 
of  the  areolae  of  the  breasts,  the  presence  of  colostrum  in  the 
breasts,  and  the  outlining  of  the  fetal  parts. 

What  are  the  signs  of  pregnancy,  doubtful,  probable, 
and  certain? 

The  doubtful  signs  of  pregnancy  are  vesical  irritability, 
irregular  gastric  disturbances,  increasing  constipation,  dimin- 
ution but  not  actual  suppression  of  the  menstrual  flow,  all 
occurring  in  a  woman  exposed  to  the  possibility  of  impreg- 
nation. 

The  probable  signs  are  total  menstrual  suppression,  in- 
creasing size  of  the  uterus,  darkening  of  the  mammary 
areola?,  development  of  Montgomery's  tubercles,  and  fre- 
quency of  micturition. 

The  certain  signs  are  the  positive  signs  already  enumerated. 

What  is  to  be  learned  by  abdominal  auscultation  in 
pregnancy? 

Auscultation  of  the  abdomen  will  reveal  the  placental 
souffle  or  uterine  bruit  and  the  fetal  heart-sounds.  Occasion- 
ally the  umbilical  souffle  may  be  detected. 

Describe  the  changes  in  position  which  the  uterus  un= 
dergoes  during  pregnancy. 

At  first  the  uterus  sinks  into  the  pelvis  on  account  of  its 
increased  specific  gravity.  There  then  follows  a  gradual  and 
progressive  rise  into  the  abdomen  until  2  to  4  weeks  before 
term,  when  a  secondary  sinking  (lightening)  occurs,  due  to 
the  entrance  of  the  fetal  head  into  the  superior  strait. 

At  what  period  does  quickening  usually  occur? 

In  the  middle  of  the  fifth  month  of  gestation. 

How  should  external  palpation  of  the  pregnant  woman 
be  performed? 

The  woman  lies  in  the  dorsal  position  with  the  limbs  partly 


OBSTETRICS  AND  GYNECOLOGY.  669 

flexed.  General  pressure  is  made  ^Yith  the  tips  of  the  fingers 
and  the  ulnar  borders  of  the  palms  upon  the  abdominal  sur- 
face from  the  median  line  towards  the  flanks.  The  hands 
are  permitted  to  dip  beneath  the  central  points  of  Poupart's 
ligaments  and  beneath  the  pelvic  brim  in  order  to  determine 
the  fetal  presentation. 

What  is  "  morning  sickness,"  when  does  it  begin,  how 
long  does  it  usually  continue,  and  what  is  its  causation 
and  treatment? 

The  nausea  and  vomiting  of  pregnancy  occui-s  usually  at 
the  sixth  week  of  gestation,  and  normally  lasts  for  six  weeks. 
It  may  begin  earlier  or  it  may  not  appear  at  all.  It  is  be- 
lieved to  be  due  to  a  reflex  irritation  of  the  nerve-endings  in 
the  uterus  resulting  from  the  rapid  growth  of  that  organ. 
It  is  best  treated  by  the  exhibition  of  nerve-sedatives,  such  as 
sodium  bromide,  ingluvin,  oxalate  of  cerium  and  the  like. 

Differentiate  ordinary  morning  sickness  from  the  hy= 
peremesis  of  pregnancy.  Mention  the  causes  and  de= 
scribe  the  management  of  the  latter. 

The  pernicious  vomiting  of  pregnancy  is  an  exaggerated 
gastric  disturbance  which  appears  to  become  uncontrollable, 
and  may  result  fatally  from  extreme  prostration.  It  is  due 
to  a  number  of  conditions,  including  the  presence  of  toxins 
of  undetermined  nature  in  the  blood,  probably  resulting  from 
imperfect  functionating  of  the  liver.  It  occurs  in  women 
whose  uteri  have  been  chronically  diseased,  and  in  those  who 
are  of  a  neurotic  tendency.  It  may  also  result  from  kidney- 
failure,  and  from  too  frequent  sexual  intercourse.  Its  treat- 
ment consists  in  proper  hygiene,  the  correction  of  uterine 
displacements  or  cervical  catarrh,  restriction  in  diet,  the  use 
of  proper  therapeutic  measures,  and,  if  need  be,  rectal  ali- 
mentation. The  pregnancy  should  be  terminated  if  the  other 
measures  fail. 

What  is  the  normal  duration  of  pregnancy?     What  are 


670  OBSTETRICS  AND  GYNECOLOGY. 

the  limits  of  the  variations,  and  how  should  its  duration 
be  calculated? 

From  a  number  of  investigations  it  has  been  found  that  in 
the  human  being  pregnancy  normally  covers  280  days  (10 
lunar  or  9  calendar  months) .  It  may  be  extended  up  to  302 
days  and  pregnancy  still  be  considered  legitimate.  Fre- 
quently the  pregnancy  terminates  prematurely,  and  this  may 
happen  at  any  time  subsequent  to  conception.  The  methods 
of  determining  the  date  of  confinement  are  numerous.  The 
Naegele  rule  is  to  count  back  3  months  from  the  date  of  the 
appearance  of  the  last  menstruation  and  add  7  days.  The 
date  of  quickening  usually  occurs  midway  through  gestation, 
or  at  4I/2  months.  Other  methods  consist  in  mensuration  of 
the  uterus  and  of  the  fetus,  and  the  use  of  periodoscopes  and 
tables. 

How  would  you  differentiate  between  the  first  and 
subsequent  pregnancies? 

In  a  primipara  the  fourchet  is  present;  it  is  missing  in  a 
multiparous  woman.  The  abdominal  walls  are  relaxed  and 
marked  wdth  striae  in  the  multipara,  while  in  the  primipara 
the  abdomen  is  full,  rounded  and  tense.  The  nipples  are 
large  and  well  developed  in  the  multiparous  woman,  and 
usually  small  and  undeveloped  in  the  primipara. 

Given  a  distended  abdomen,  how  would  you  differen= 
tially  diagnose  pregnancy,  ovarian  disease,  ascites,  and 
gaseous  accumulation? 

In  ovarian  cyst  there  is  generally  an  absence  of  the  chief 
signs  of  pregnancy ;  the  characteristic  ovarian  f acies  is  pres- 
ent; the  abdominal  tumor  is  soft,  fluctuating,  usually  more 
or  Icvss  directed  to  one  side,  and  does  not  reveal  the  fetal  signs; 
continuance  of  menstruation  is  the  rule;  the  cervix  is  not 
unduly  soft;  and  the  histoiy  is  obscure,  the  growth  slowly 
developing  for  a  longer  period  than  the  full  term  of  gestation. 

In  ascites  percussion  shows  dulness  in  the  flanks,  with  re- 
sonance in   the  median   abdominal  line,   the   area  of  dulness 


OBSTETRICS  AND  GYNECOLOGY.  671 

changing  with  the  position  of  the  patient;  there  is  free  fluc- 
tuation; the  usual  signs  of  pregnancy  are  absent;  the  abdo- 
men is  flattened  in  the  umbilical  region,  with  bulging  at  the 
sides;  the  umbilicus  is  always  depressed;  palpation  does  not 
reveal  any  definite  tumor;  the  cervix  is  not  altered. 

In  gaseous  accumulation  or  pseudocyesis,  which  most  com- 
monly occurs  in  elderly  women  at  or  near  the  menopause  or  in 
young  or  hysterical  women,  some  of  the  important  signs  of 
pregnancy  will  be  absent;  the  uterus  is  not  enlarged,  and  the 
cer\'ix  is  not  soft ;  there  is  a  tympanitic  percussion-note  over 
the  whole  abdominal  surface,  and  if  the  patient  be  anesthe- 
tized the  abdominal  enlargement  will  disappear  entirely. 

Differentiate  uterine  bruit  and  umbilical  souffle. 

The  uterine  bruit  or  placental  souffle  is  a  rhythmic  blowing 
sound  occurring  synchronously  with  the  maternal  heart-beat. 
It  is  first  heard  about  the  beginning  of  the  fourth  month,  and 
is  generally  located  low  down  and  to  one  or  the  other  side  of 
the  uterus.  It  is  also  known  as  the  placental  murmur.  The 
umbilical  or  funic  souffle  is  a  peculiar  high-pitched  hissing 
sound  heard  most  distinctly  in  the  immediate  vicinity  of  the 
fetal  heart,  with  the  beat  of  which  it  is  synchronous.  It  is  a 
sign  of  fetal  danger,  and  indicates  some  stenosis  of  the  um- 
bilical arteries. 

Describe  the  mammary  glands  and  the  changes  they 
undergo  in  pregnancy.  When  the  child  is  still-born  what 
care  should  be  taken  of  the  mother's  breasts? 

The  mammary^  glands  are  two  large  glandular  structures 
on  the  anterior  surface  of  the  thorax.  They  consist  of  a  num- 
ber of  lobules,  each  of  which  has  an  excretory  or  galacto- 
phorous  duct  which  runs  to  the  nipple.  During  pregnancy 
the  breasts  enlarge  and  become  firm  and  heavy.  Glistening 
streaks  appear  upon  the  surfaces  from  over-distension.  Pig- 
ment is  deposited  around  the  nipple  in  the  areolae;  the  glands 
of  Montgomery  enlarge  and  protrude  from  the  surface;  the 
nipples  increase  in  size  and  bocnnic  prominent  mikI  pr<itnid- 


672  OBSTETRICS  AND  GYNECOLOGY. 

ing.  Colostrum  appears  in  the  breast  after  the  third  month. 
If  the  child  is  still-born  the  breasts  must  be  strapped  and 
applications  made  to  prevent  the  development  of  milk. 

State  the  medico^legal  complications  that  may  arise 
from  an  erroneous  diagnosis  of  pregnancy. 

An  erroneous  diagnosis  of  pregnancy  may  result  in  con- 
jugal unhappiness,  with  divorce;  it  may  cause  the  execution 
of  an  innocent  woman  or  unnecessary  confinement  in  prison; 
it  may  alter  the  terms  of  a  will  or  the  dividing  of  an  estate; 
it  may  bring  a  law-suit  against  the  physician. 

What  are  the  positions  and  attitudes  of  the  fetus  in 
utero,  and  what  are  their  causes? 

The  fetus  may  lie  parallel  with  or  at  right  angles  to  the 
long  axis  of  the  woman's  body;  it  always  lies  in  a  long  axis 
of  the  uterus,  whether  this  be  horizontal  or  vertical.  It  may 
lie  obliquely  if  there  exist  a  tumor  or  thickening  in  the  uterine 
wall,  or  if  the  uterine  cavity  be  irregular  in  its  outlines. 

How  many  different  presentations  are  liable  to  be  met 
in  obstetric  practice?     What  are  they? 

There  are  three  presentations  of  the  fetal  body,  viz.,  the 
cephalic  or  head,  the  pelvic,  and  the  transverse  or  trunk. 
The  cephalic  presentations  include  the  vertex,  face,  bregma 
■or  anterior  fontanel,  broiv,  ear,  and  parietal  eminence.  The 
pelvic  presentations  include  the  breech,  knee,  and  foot. 

How  is  a  vertex  presentation  recognized  by  palpation? 

Examination  of  the  abdomen  shows  the  hard  cephalic  ex- 
tremity of  the  child  at  the  pelvic  brim;  vaginal  examination 
reveals  the  depressed  occiput  and  smaller  fontanel  at  one 
extremity  of  a  pelvic  diameter,  while  the  sagittal  suture 
extends  obliquely  from  them  in  the  line  of  the  diameter. 

Differentiate  the  positions  of  the  fetus  at  term  as  deter- 
mined by  external  palpation. 

Cephalic  or  head  presentations  show  the  fetal  ellipse  lying 
longitudinally,  with  the  fetal  back  to  one  or  the  other  side 


OBSTETRICS  AND  GYNECOLOGY.  673 

and  the  hard  cephalic  extremity  at  the  pelvic  brim;  fetal 
movements  are  felt  high  up  on  the  abdominal  surface.  In 
pelvic  presentations  the  conditions  are  reversed,  the  head 
above  and  the  breech  below;  the  head  may  be  freely  moved, 
and  the  fetal  movements  are  felt  low  down  on  the  abdominal 
surface.  In  transverse  presentations  the  long  axis  of  the 
fetus  lies  at  right  angles  to  the  long  axis  of  the  mother's  body ; 
both  extremities  of  the  fetal  ellipse  may  be  readily  palpated. 

How  may  the  knee  be  distinguished  from  the  elbow 
when  presenting? 

The  knee  is  round  and  large,  the  elbow  small  and  more 
angular;  the  elbow  shows  sharp  bony  processes  to  the  sides 
and  posterior;  the  politeal  space  may  be  felt  behind  the 
knee;  the  arm  may  readily  be  brought  down  if  the  elbow  is 
present;  the  leg  is  brought  down  with  more  difficulty. 

What  is  understood  by  the  hygiene  of  pregnancy?  In 
a  case  of  pregnancy  how  is  the  health  of  the  patient  main= 
tained? 

By  the  hygiene  of  pregnancy  is  meant  the  management  of 
the  patient  according  to  the  rules  of  health.  This  includes 
regulation  of  the  diet,  clothing,  exercise,  bathing  and  douch- 
ing, and  sexual  intercourse;  attention  to  the  kidneys  and 
other  emunctories;  the  correction  of  constipation  and  proper 
occupation  for  the  mind. 

Describe  the  proper  management  of  the  breasts  of  the 
mother  before  labor. 

Proper  development  of  the  nipples  should  be  favored  by 
judicious  manipulation  daily.  The  nipples  should  be  kept 
clean  by  soap  and  water  and  a  weak  solution  of  sodium  borate. 
If  the  breasts  are  painful  they  may  be  anointed  at  night  with 
cocoa-butter  or  lanolin. 

What  is  the  pathology  of  pregnancy?  Name  some  of 
the  diseases  to  which  pregnancy  predisposes. 

The  pathology  of  pregnancy  includes  a  study  of  the  dis- 
43 


674  OBSTETRICS  AND  GYNECOLOGY. 

eases  to  which  a  pregnant  woman  is  exposed.  The  diseases 
she  is  most  apt  to  develop  are  renal  insufficiency,  Bright 's- 
disease,  gingivitis,  salivation,  pica,  indigestion,  pernicious 
vomiting,  constipation,  hemorrhoids,  jaundice,  appendicitis, 
dyspnea,  cardiac  palpitation,  hydremia,  pernicious  anemia,, 
varicose  veins,  hemorrhage,  uterine  displacements,  insanity,, 
neuralgias,  and  osteomalacia. 

To  what  form  of  morbus  Brightii  are  pregnant  women 
most  liable?     How  would  you  diagnose  and  treat  it? 

To  acute  nephritis,  catarrhal  or  interstitial  in  nature.  It 
is  frequently  so  called  when  in  reality  the  kidney  of  preg- 
nancy is  meant. 

Give  the  etiology,  symptoms  and  management,  as  best 
understood  and  practiced  at  present,  of  albuminuria  of 
pregnancy.     What  is  the  prognosis? 

By  the  alhuminuria  or  kidney  of  pregnancy  is  meant  a 
peculiar  condition  manifested  by  a  certain  proportion  of 
pregnant  women  in  which  albumin  appears  in  the  urine  in 
varying  amounts,  but  which  is  unassociated  with  any  grave 
organic  change  in  the  kidneys.  The  condition  is  one  of  hemic 
intoxication,  the  poisons  probably  originating  in  an  imper- 
fect metabolism  on  the  part  of  the  liver.  The  poisons  irritate 
the  kidneys,  producing  an  arteriole  contraction,  whereby  the 
kidneys  appear  pale  and  anemic,  and  become  inadequate  to 
perform  the  work  devolved  upon  them.  The  treatment  of 
renal  inadequacy  consists  in  a  careful  supervision  of  the 
condition  of  the  urine,  and  appropriate  dietetic,  hygienic  and 
therapeutic  regimen.  Milk  diet  or  light  diet,  large  draughts 
of  Poland  or  lithia  water,  diuretics,  laxatives,  alteratives, 
Basham's  mixture,  irrigation  of  the  bowel  with  hot  normal 
saline  solutions,  and  the  bromides  and  chloral  hydrate  consti- 
tute the  treatment.  If  the  disease  progresses  labor  may  have 
to  be  induced.     The  prognosis  is  always  anxious. 

How   would    you    measure    the    severity    of    interstitial 


OBSTETRICS  AND  GYNECOLOGY.  675 

nephritis  in  a  pregnant  woman,  and  how  would  you  treat 
such  a  condition? 

By  the  early  appearance  of  the  symptoms,  by  the  number 
and  nature  of  the  urinary  casts,  by  the  development  of  albu- 
minuric retinitis,  and  by  the  rapidly  increasing  edema.  The 
disease  requires  an  early  evacuation  of  the  uterine  contents. 

What  is  the  cause  of  difficult  and  painful  urination  in 
pregnancy? 

When  present  this  generally  results  from  uterine  displac- 
ment  backward,  the  cervix  tilting  up  against  the  base  of  the 
bladder  and  interfering  with  micturition. 

How  do  uterine  displacements  originate,  and  how  do 
they  influence  conception  and  pregnancy? 

Uterine  displacements  are  generally  the  result  of  previous 
labors,  the  floor  being  lacerated  and  the  uterus  remaining 
.subinvoluted  and  heavy.  Such  an  organ  falls  back  into  the 
hollow  of  the  sacrum.  Anteflexion  of  the  uterus  may  result 
from  a  ventrofixation.  Any  fixed  displacement  is  apt  to  pre- 
vent conception  by  rendering  the  ingress  of  the  spermatozoids 
impossible,  and  if  pregnancy  results  and  the  displacement 
persists,  abortion  is  apt  to  occur  spontaneously. 

What  uterine  displacement  is  especially  liable  to  inter- 
rupt pregnancy,  and  what  should  be  done  to  prevent  it? 

Retrodisplacement.  Such  a  displaced  uterus  should  be 
replaced  at  once,  and  a  pessary  introduced  and  retained  until 
the  fundus  rises  above  the  sacral  promontory  (fourth  month)  ; 
it  may  then  be  withdrawn. 

What  treatment  would  you  advise  for  a  case  of  con- 
tinued menstruation  during  pregnancy? 

Such  a  condition  indicates  failure  of  union  between  the 
decidua  vera  and  decidua  reflexa.  The  patient  should  be 
kept  quiet,  especially  at  the  menstrual  epochs.  No  local 
treatment  is  indicated  as  a  rule.  If  the  hemorrhage  becomes 
profuse  the  treatment  of  threatened  abortion  must  be  insti- 
tuted. 


676  OBSTETRICS  AND  GYNECOLOGY. 

Name  the  diseases  of  the  endometrium,  and  state  their 
effects  in  pregnancy. 

Inflammation  (endometritis) ,  acute  or  chronic,  will  tend 
to  produce  abortion.  Chronic  endometritis,  especially  if 
syphilitic  in  origin,  is  probably  the  most  common  cause  of 
abortion.  Atrophy  of  the  decidua  (hypertrophied  endome- 
trium) causes  the  ovum  to  drop  in  the  uterine  cavity,  and 
may  result  in  placenta  prsevia.  A  catarrhal  endometritis 
may  cause  an  accumulation  of  fluid  between  the  layers  of  the 
decidua,  producing  the  condition  known  as  hydrorrhcea  gravi- 
darum, or  "false  waters."  Apoplexy  of  the  decidua  may 
destroy  the  ovum.  Tumors  may  form  in  the  decidua  rarely; 
if  benign  they  are  known  as  benign  deeiduomata;  malignant 
deciduoma  is  rarely  encountered. 

What  diseases  of  the  mother  are  liable  to  injure  the 
fetus  in  utero? 

Syphilis,  tuberculosis,  rickets,  the  exanthemata,  renal  in- 
adequacy, puerperal  eclampsia;  any  disease  causing  stagna- 
tion in  the  circulation,  as  chronic  valvular  disease  and  spas- 
modic maternal  affections,  as  bronchitis,  chorea  and  the  like. 

Mention  some  of  the  principal  causes  of  sterility  in 
woman,  and  state  how  fertility  may  be  promoted. 

Stenosis  of  the  cervical  canal  from  anteflexion,  retrodis- 
placement  of  the  uterus,  cervical  catarrh  with  profuse  acrid 
leukorrhea,  chronic  salpingitis  resulting  in  occlusion  of  the 
Fallopian  tubes,  and  chronic  endometritis.  Rapid  progressive 
dilatation  of  a  stenosed  canal,  replacement  of  a  displaced 
uterus,  the  local  treatment  of  cervical  catarrh  and  uterine 
disease  will  do  much  to  restore  a  normal  condition  and  pro- 
mote fertility. 

Define  abortion,  miscarriage,  and  premature  labor. 

Abortion  is  the  discharge  of  the  ovum  during  the  first  tri- 
mester of  pregnancy.  Miscarriage  is  the  discharge  of  the 
embryo  during  the  second  trimester.     Premature  labor  is  the 


OBSTETRICS  AND  GYNECOLOGY.  677 

delivery  of  the  fetus  after  the  period  of  viability  and  before 
full  term. 

What  is  the  management  of  abortion,  both  preventive 
and  curative?  Give  its  causes,  diagnosis,  and  indications 
for  treatment. 

The  causes  of  abortion  are  numerous.  They  include  cer- 
tain morbid  states  of  the  ovum  and  fetus,  as  apoplexy  of  the 
ovum,  disease  of  the  umbilical  vesicle,  disease  of  the  fetal 
membranes,  malposition  of  the  placenta,  disease  of  the  fetus, 
as  syphilis  and  hydrocephalus,  death  of  the  fetus,  certain 
paternal  causes,  as  a  diseased  spermatozoid,  certain  maternal 
diseases,  as  the  exanthemata,  valvular  heart-disease,  renal 
inadequacy,  convulsive  disorders,  as  chorea  and  epilepsy, 
malformations  of  the  uterus,  profound  mental  shock,  and 
traumatism. 

The  symptoms  of  abortion  are  sacral  discomfort,  steadily 
increasing  hemorrhage,  uterine  contractions,  and  finally  ex- 
pulsion of  a  part  or  the  whole  of  the  product  of  conception. 
The  diagnosis  may  be  made  by  a  study  of  the  symptoms,  by 
the  physical  signs,  and  by  an  examination  of  the  discharged 
products.  The  preventive  treatment  consists  in  absolute 
quiet  and  rest  in  bed,  lowering  of  the  head,  the  administra- 
tion of  nerve-sedatives,  as  sodium  bromid,  and  the  introduc- 
tion of  an  opium  suppository.  The  curative  treatment  con- 
sists in  vaginal  and  cervical  tamponade  to  control  bleeding, 
followed  by  emptying  of  the  uterine  contents. 

What  are  the  premonitory  symptoms  of  abortion? 

At  the  best  these  are  vague  and  unreliable.  They  consist 
in  a  sense  of  discomfort  or  fulness  in  the  pelvis,  sacral  pains, 
a  feeling  of  malaise,  a  tendency  to  vesical  tenesmus,  chilly 
sensations,  and  beginning  discharge  of  serum  or  blood  from 
the  uterus. 

What  are  the  symptoms  of  threatened  abortion? 

Pain,  increasing  hemorrhage,  and  opening  of  the  uterine 
month. 


678  OBSTETRICS  AND  GYNECOLOGY. 

Describe  the  symptoms  and  give  the  management  of  an 
incomplete  abortion. 

The  body  of  the  uterus  will  be  large,  soft  and  boggy;  the 
cervical  canal  will  be  patulous ;  the  finger  introduced  into 
the  cavity  of  the  uterus  will  detect  clots,  fragments  of  mem- 
brane and  pieces  of  soft,  pulpy,  placental  tissue ;  the  discharge 
will  be  dark,  hemorrhagic  and  grumous,  and  there  may  or 
may  not  be  a  fetid  odor.  The  treatment  consists  in  the  asep- 
tic removal  of  the  uterine  contents  by  means  of  the  finger  or 
placental  forceps,  followed  by  an  intra-uterine  douche  of  mer- 
curic chlorid,  1-4000,  and  the  administration  of  small  doses 
of  ergot  if  the  hemorrhage  persist. 

What  are  the  symptoms  of  an  inevitable  abortion? 

Steadily  increasing  hemorrhage  and  pain  despite  the  pre- 
ventive treatment,  and  the  presence  of  Tarnier's  sign,  namely, 
obliteration  of  the  angle  of  flexion  between  the  upper  and 
lower  uterine  segments  by  the  descent  of  the  detached  ovum. 

What  means  should  be  employed  to  prevent  threatened 
abortion  during  the  first  three  months  of  pregnancy? 

The  avoidance  of  over-exertion,  the  correction  of  uterine 
displacement,  rest  in  bed  at  the  menstrual  epochs,  the  admin- 
istration of  sodium  bromide,  viburnum  prunifolium  and  other 
sedatives,  and  occasionally  the  use  of  an  opium  suppository. 

How  should  inevitable  abortion  be  managed? 

A  vaginal  and  intracervical  tampon  should  be  introduced 
and  left  in  situ  for  8  hours.  On  its  removal  the  ovum  will 
probably  be  found  attached  to  it.  If  not,  a  second  tampon 
may  be  introduced  and  retained  for  from  6  to  8  hours.  If  this 
fails  to  bring  the  ovum  away,  the  patient  should  be  anesthe- 
tized and  the  product  removed  by  the  finger  or  the  placental 
forceps. 

When  and  how  should  abortion  be  induced? 

The  induction  of  abortion  is  indicated  when  maternal  life 
is  menaced  by  some  grave  pathologic  state  of  the  fetus  or  of 


OBSTETRICS  AND  GYNECOLOGY.  679 

the  mother,  as  cystic  disease  of  the  chorion,  acute  hydramnios, 
large  uterine  or  pelvic  tumors,  extreme  pelvic  contraction, 
pernicious  vomiting,  pernicious  anemia,  chronic  nephritis 
and  the  like.  The  best  method  of  inducing  abortion  consists 
in  rapid  dilatation  of  the  cervix  after  thorough  asepsis  of  the 
vagina,  with  the  immediate  removal  of  the  ovum  by  the  finger 
and  placental  forceps. 

Is  the  production  of  premature  labor  ever  justifiable? 
If  so,  when  and  how  would  you  accomplish  that  object? 

The  indications  for  the  induction  of  premature  labor  in- 
clude all  conditions  menacing  fetal  or  maternal  life,  as  well 
as  those  pathologic  states  of  either  mother  or  child  that  will, 
if  the  pregnancy  be  allowed  to  continue  to  term,  be  productive 
of  grave  degrees  of  dystocia.  These  are,  oversize  or  prema- 
ture ossification  of  the  upper  portion  of  the  fetal  skull,  acute 
hydramnios  occurring  late  in  pregnancy,  habitual  death  of 
the  fetus  during  the  last  days  or  weeks  of  pregnancy,  pelvic 
deformity,  placenta  previa,  pernicious  anemia,  pernicious 
vomiting,  increasing  albuminuria,  eclampsia,  grave  valvular 
disease,  advanced  pulmonary  tuberculosis,  tumors  in  the  pel- 
vic canal.  The  best  method  of  inducing  labor  is  the  intro- 
duction of  an  aseptic  rubber  catheter  into  the  uterus.  Other 
methods  include  the  use  of  Barnes'  or  Champetier  de  Ribes' 
bags,  and  rapid  digital  divulsion  of  the  cervix  with  the  per- 
formance of  podalie  version. 

Define  and  classify  ectopic  pregnancy.  Give  its  causes, 
symptoms  and  treatment. 

Ectopic  or  extra-uterine  pregnancy  is  a  generic  terra  mean- 
ing pregnancy  at  any  point  outside  of  the  uterus.  This 
includes  tuhnl  pregnancy,  interstitial  pregnancy,  tuho-ovarian- 
pregnancy,  ovarian  pregnancy,  and  primary  and  secondary 
abdominal  pregnancy.  The  causes  of  this  condition  are  un- 
known. The  condition  is  generally  encountered  in  women 
who  are  between  20  and  30  years  of  age,  and  who  present  a 
history  of  a  protracted  period  of  sterility  following  one  or 


680  OBSTETRICS  AND  GYNECOLOGY. 

more  pregnancies.  It  was  formerly  believed  to  be  due  to  a 
sialpingitis,  but  Sutton  now  states  that  it  is  more  liable  to 
occur  in  a  healthy  tube.  Tubal  diverticula  may  produce  it. 
The  symptoms  are  the  presence  of  all  the  signs  of  early  ges- 
tation, irregularity  in  the  menstrual  history,  vaginal  pulsa- 
tion, lancinating,  cramp-like  pains  in  the  afifected  side,  slight 
elevation  of  temperature,  and  lateral  displacement  of  the 
uterus  by  a  very  sensitive  mass.  The  treatment  consists  in 
immediate  abdominal  section  and  removal  of  the  gestation-sac. 

What  are  some  of  the  possible  terminations  of  a  tubal 
pregnancy? 

Tubal  pregnancy  may  terminate  in  rupture,  which  is  usual. 
In  a  certain  percentage  of  cases  the  embryo  may  die  within 
the  first  few  weeks  of  gestation;  this  is  known  as  the  sponta- 
neous cure  of  extra-uterine  pregnancy.  Rarely  the  condition 
may  go  to  term. 

What  are  the  symptoms  of  rupture  in  ectopic  preg= 
nancy?     What  should  be  done  when  such  rupture  occurs? 

The  symptoms  of  rupture  are  sudden  and  characteristic. 
They  consist  in  exceedingly  severe  cramp-like  pains  in  the 
iliac  region  of  the  affected  side,  associated  with  collapse  and 
the  symptoms  of  concealed  hemorrhage,  namely,  extreme 
pallor  of  the  surface,  feeble  running  pulse,  air-hunger,  moist, 
clammy  skin,  coldness  of  the  extremities,  vomiting,  and  fre- 
quently coma.  There  is  an  increased  discharge  from  the 
vagina ;  large  masses  of  decidual  tissue  are  usually  discharged 
at  this  time.     Immediate  laparotomy  should  be  performed. 

What  preliminary  preparations  would  you  suggest  for 
a  case  of  labor? 

The  thorough  disinfection  of  the  physician,  nurse  and 
patient  according  to  the  accepted  methods,  the  opening  of  the 
patient's  bowels  by  means  of  a  rectal  enema,  the  proper 
preparation  of  the  patient's  clothing  and  bed.  The  nurse 
should  have  on  hand  the  various  drugs  and  instruments,  as 
well  as  hot  water,  for  whatever  obstetric  operation  may  be 
required. 


OBSTETRICS  AND  GYNECOLOGY.  681 

What  is  labor? 

Labor  is  that  natural  process  by  which  a  pregnant  woman 
trxpels  the  product  of  conception  at  the  full  expiration  of  the 
period  of  pregnancy,  280  days  after  conception. 

Into  what  stages  is  labor  divided,  and  where  do  these 
stages  begin  and  end? 

There  are  three  stage  of  labor.  The  first  or  stage  of  dila- 
tation begins  with  the  first  labor  pain  and  continues  until  the 
OS  is  fully  dilated.  The  second  stage  or  stage  of  expulsion 
extends  from  full  dilatation  until  the  delivery  of  the  child 
is  accomplished.  The  third  stage  or  stage  of  the  placenta 
extends  from  the  delivery  of  the  child  until  the  expulsion  of 
the  after-birth. 

What  are  the  prodromata  of  labor? 

The  onset  of  labor  is  indicated  from  2  to  4  weeks  before  by 
the  phenomenon  known  as  lightening.  This  is  produced  by 
the  entrance  of  the  child's  head  into  the  superior  strait,  and 
occurs  2  weeks  before  term  in  multipara?  and  4  weeks  before 
term  in  primiparae.  The  symptoms  of  beginning  labor  are 
pain,  beginning  dilatation  of  the  os,  and  a  bloody  discharge 
known  as  the  show. 

What  is  the  diagnosis  of  false  from  true  labor  pains? 

False  labor  pains  are  annoying,  colicky  sensations  occur- 
ring during  the  last  2  or  3  weeks  of  pregnancy,  which  usually 
depend  upon  constipation  or  pressure  upon  nerve-trunks. 
They  are  irregular  in  their  location,  and  are  not  accompanied 
by  dilatation  of  the  os.  True  labor  pains  are  involuntary 
and  painful  contractions  of  the  uterine  muscles  occurring 
intermittently  and  with  increasing  severity  at  decreasing  in- 
tervals. They  are  usually  felt  in  the  small  of  the  back,  and 
from  this  point  pass  around  the  abdomen.  They  may  reverse 
this  direction,  and  commencing  at  the  umbilicus,  pass  back- 
ward to  the  sacrum.  They  are  cumulative  in  nature,  of 
unequal  intensity,  and  hist  from  one-half  to  one  minute. 
They  result  in  dilatation  of  the  os. 


t)«2  OBSTETRICS  AND  GYNECOLOGY. 

Give  the  character,  situation  and  cause  of  the  pains 
during  the  first  and  second  stages  of  labor. 

During  the  first  stage  of  labor  the  pains  are  as  described  in 
the  foregoing  answer.  They  result  from  squeezing  of  the 
nerve-fibrils  by  the  contracting  of  the  uterine  muscles.  They 
are  colicky  in  nature,  and  aside  from  opening  the  os  do  not 
favor  the  expulsion  of  the  child.  In  the  second  stage  of  labor 
the  character  of  the  pains  changes.  They  become  bearing- 
down  or  expulsive  in  nature.  The  pain  now  is  due  to  pres- 
sure upon  the  soft  tissues  of  the  lower  parturient  canal,  as 
well  as  to  the  pressure  upon  the  nerve-fibrils  above. 

What  means  are  employed  to  stimulate  ineffective 
uterine  contractions? 

The  administration  of  quinine  in  large  doses,  the  application 
of  a  firm  abdominal  binder,  keeping  the  woman  upon  her  feet, 
and  the  taking  of  a  small  amount  of  food  may  all  result  in  an 
increase  of  the  uterine  pain.  Ergot  or  its  substitutes  should 
not  be  administered. 

What  is  meant  by  the  mechanism  of  labor? 

By  the  mechanism  of  labor  is  meant  the  manner  in  which 
the  fetus  and  secundines  pass  through  the  parturient  canal 
and  are  expelled. 

Define  and  differentiate  position,  presentation,  and  ro=" 
tation. 

By  position  is  meant:  1.  The  varying  relationship  borne 
by  the  most  prominent  point  of  the  presenting  part  of  the 
fetus  to  the  cardinal  points  of  the  pelvis.  2.  The  relationship 
existing  between  the  long  axis  of  the  fetus  and  that  of  the 
maternal  body. 

By  presentation  is  meant  that  portion  of  the  fetal  body 
which  is  detected  by  the  examining  finger  introduced  to  the 
center  of  the  plane  of  the  superior  strait. 

By  rotation  is  meant  the  turning  of  the  presenting  part 
from  right  to  left  or  left  to  right  after  it  has  struck  the  pelvic 


OBSTETRICS  AND  GYNECOLOGY.  683 

floor,  so  that  it  comes  to  present  under  the  pubic  symphysis. 
External  rotation  is  a  return  of  the  presenting  part  to  the 
side  from  which  it  comes  after  it  has  been  delivered  through 
the  vulvar  orifice. 

Give  the  normal  vertex  presentations  in  the  order  of 
their  frequency. 

1.  Left  occipito-anterior,  L.  0.  A.;  2.  Right  occipito-pos- 
terior,  R.  0.  P.;  3.  Right  occipito-anterior,  R.  0.  A.;  4.  Left 
occipito-posterior,  L.  0.  P. 

What  is  the  most  common  presentation  and  which  the 
most  frequent  position  of  the  presenting  part  in  normal 
labor?     Give  the  average  duration  of  a  natural  labor. 

The  most  common  fetal  presentation  is  the  occipital  or 
vertex;  the  most  frequent  position  is  the  left  occipito-anterior. 
L.  0.  A.  The  average  duration  of  labor  in  a  primipara  is 
from  12  to  15  hours ;  in  a  multipara  from  8  to  10  hours. 

Give  the  formation  of  the  caput  succedaneum.  Where 
does  the  caput  succedaneum  appear  in  the  third  position? 

The  caput  succedaneum  or  "accessory  head'"  is  the  tumor 
situated  upon  the  presenting  part  of  the  fetus.  It  is  formed 
by  a  serosanguineous  infiltration  of  the  connective  tissue  of 
the  part.  It  is  due  to  an  edema  of  ;the  part  that  is  not  com- 
pressed by  the  maternal  structures.  In  the  third  position 
of  the  vertex,  R.  O.  P.,  the  caput  appears  on  the  left  parietal 
eminence. 

Describe  the  mechanism  of  labor  in  L.  O.  A.  presen- 
tation. 

Adaptation  of  the  fetal  presentation  to  the  pelvic  strait. 
It  consists  of  three  steps,  namely,  preliminary  flexion  and 
moulding  occurring  with  the  phenomenon  of  lightening;  fur- 
ther flexion  and  moulding  occurring  with  the  first  labor  pains : 
and  Naegele's  obliquity,  or  lateral  inclination  of  the  fetal  head 
toward  the  maternal  sacrum,  the  right  parietal  bone  pre.sent- 
ing.     The  birth-canal   is  next  prepared  by  being  dilated  by 


684  OBSTETRICS  AND  GYNECOLOGY. 

means  of  the  bag  of  waters.  The  presentation  next  descends 
to  the  pelvic  floor,  the  occiput  resting  on  the  floor.  Internal 
anterior  rotation  of  the  occiput  from  left  to  right  now  occurs, 
the  occiput  resting  beneath  the  symphysis  pubis.  Birth  of 
the  head  by  a  process  of  extension  follows,  the  perineum 
retracting  over  the  face,  which  appears  first  at  the  forehead 
and  eyes  and  finally  at  the  chin.  Restitution  or  untwisting 
of  the  neck  is  then  followed  by  external  rotation  of  the  head, 
which  becomes  transveres,  with  the  occiput  to  the  left  side. 
The  birth  of  the  shoulders  follows,  the  anterior  or  right  shoul- 
der rotating  from  right  to  left;  the  rest  of  the  trunk  is  then 
rapidly  expelled. 

Describe  the  mechanism  of  labor  in  the  L.  O.  P.  position. 

The  steps  of  the  mechanism  are  the  same  as  in  the  foregoing 
except  that  the  head  has  further  to  rotate  in  order  to  reach 
the  symphysis,  and  this  excessive  rotation  requires  a  rotation 
of  the  shoulders  at  the  superior  strait  from  the  right  into  the 
left  oblique  diameter,  the  anterior  shoulder  rotating  from 
left  to  right.  After  restitution  this  shoulder  rotates  back 
again  to  the  middle  line  from  right  to  left.  The  rest  of  the 
mechanism  is  as  in  the  L.  0.  A.  presentations. 

Name  and  describe  the  various  forms  of  head=presenta= 
tion,  with  the  management  appropriate  to  each. 

The  vertex  presentation  is  most  common;  its  management 
is  that  of  an  ordinary  case  of  labor.  Brow  and  face  presen- 
tations are  always  abnormal,  and  will  be  described  further 
on.  Presentation  of  the  bregma  is  the  so-called  ' '  military  posi- 
tion" of  the  fetus,  the  head  being  midway  between  flexion  and 
extension,  and  set  squarely  on  the  shoulders.  The  large 
occipito-frontal  diameter  of  the  fetal  skull  (11%  cm.)  pre- 
sents. This  presentation  must  be  converted  into  an  occipital 
presentation  in  order  to  permit  labor  to  proceed.  Ear  pre- 
sentation is  a  laterally  deviated  vertex  presentation,  and  can 
generally  be  corrected  manually  or  by  altering  the  position 
of  the  patient. 


OBSTETRICS  AND  GYNECOLOGY.  685 

Give  the  face  and  breech  presentations  of  the  fetus. 

The  face  presentations  are :  1.  Left  mento-anterior,  L.  M. 
A. ;  2.  Right  mento-anterior,  R.  M.  A. ;  3.  Right  mento-pos- 
terior,  R.  M.  P. ;  4.  Left  mento-posterior,  L.  M.  P.  The 
hreech  presentations  are :  1.  Left  saero-anterior,  L.  S.  A. ;  2. 
Right  saero-anterior,  R.  S.  A,;  3.  Right  saero-posterior, 
R.  S.  P. ;  4.  Left  saero-posterior,  L.  S.  P. 

Give  the  causes  of  cephalic  presentations,  and  state  why 
vertex  presentations  are  favorable. 

The  causes  of  cephalic  presentation  are :  1.  The  peculiar 
shape  of  the  uterus  and  of  the  fetal  ellipse,  the  smaller  ex- 
tremity of  the  fetal  ellipse  accommodating  itself  to  the  smaller 
portion  of  the  uterine  cavity;  2.  The  fetal  center  of  gravity 
lies  near  the  head,  which  becomes  the  dependent  portion. 

How  would  you  know  a  head»presentation?  How  a 
breech  presentation?     How  a  transverse  presentation? 

In  cephalic  presentations  palpation  externally  reveals  the 
hard  fetal  skull  at  the  superior  strait;  vaginal  examination 
will  reveal  the  dome-like  projection  of  the  brow  or  the  vertex, 
or  the  features  of  the  face.  In  hreech  presentations,  if  the 
membranes  have  broken,  there  will  be  a  discharge  of  meco- 
nium; palpation  will  also  show  the  soft  pelvic  structures, 
while  externally  the  head  can  be  felt  at  the  upper  portion  of 
the  abdominal  wall.  In  transverse  presentation  the  long  axis 
of  the  fetus  lies  at  right  angles  to  the  long  axis  of  the  maternal 
body;  vaginal  examination  is  liable  to  show  an  arm  or  elbow 
presenting. 

Describe  the  mechanism  of  expulsion  in  natural  labor. 

Expulsion  is  accomplished  by  the  direct  action  of  the 
uterine  muscles  upon  the  fetal  body.  The  fetus  is  expelled 
because  there  is  a  decided  diminution  in  the  intra-uterine 
space,  and  the  intra-uterine  contents  are  propelled  in  the 
direction  of  least  resistance,  down  the  lower  canal. 


686  OBSTETRICS  AND  GYNECOLOGY. 

What  is  the  "  bag  of  waters,"  its  functions  and  man- 
agement during  labor? 

The  bag  of  waters  is  the  tough  elastic  membrane  containing 
the  liquor  amnii,  whiehi  can  be  felt  protruding  through  the 
OS  during  the  process  of  dilatation.  Its  function  in  labor  is 
to  distend  the  cervical  fibers,  which  it  does  by  hydraulic  pres- 
sure. It  should  never  be  ruptured  in  primiparous  women, 
and  in  multipara  only  after  full  dilatation  of  the  os  has  been 
accomplished. 

State  the  causes  of  dilatation  of  the  os  and  cervix  uteri 
as  related  to  labor. 

There  are  two  causes  of  cervical  dilatation  in  labor,  namely, 
the  wedge-like  action  of  the  bag  of  waters  acting  on  the 
edematous  cervical  tissues,  and  the  upward  traction  exerted 
by  the  longitudinal  layer  of  muscular  fibers  in  the  uterine 
walls. 

Give  a  brief  description  of  the  three  stages  of  labor. 

During  the  first  stage  of  labor  the  pains  occur  at  intervals 
of  5  to  30  minutes;  they  accomplish  during  this  time  the 
dilatation  of  the  os.  This  stage  may  take  from  2  to  20  hours, 
and  the  patient  for  most  of  this  time  may  remain  out  of  bed. 
In  the  second  or  expulsive  stage,  the  patient  lying  in  bed,  the 
pains  occur  every  %  to  5  minutes,  and  are  assisted  by  volun- 
tary bearing-down  on  the  part  of  the  patient.  This  drives 
the  presentation  down  upon  the  perineum,  which  bulges,  and 
by  its  resistance  directs  the  presentation  to  the  vulvar  orifice, 
through  which  it  finally  emerges.  This  stage  consumes  from 
30  minutes  to  2  hours.  The  third  stage,  which  seldom  lasts 
over  half  an  hour,  consists  in  the  expulsion  of  the  placenta 
and  membranes. 

What  may  cause  premature  rupture  of  the  membrane? 
How  may  this  rupture  influence  the  progress  and  conduct 
of  labor? 

Undue  tenuity  of  the  membranes  may  cause  rupture  to 
occur  with  the  first  labor  pains.     They  may  also  be  ruptured 


OBSTETRICS  AND  GYNECOLOGY.  687 

by  the  careless  introduction  of  the  finger  dunng  a  pain. 
When  the  water  escapes  early  the  labor  is  said  to  be  "dry." 
This  results  in  slow  progress  of  the  presenting  part,  and  in 
tedious  dilatation  of  the  os.  The  cervix  is  liable  to  extensive 
lacerations  in  such  cases. 

Give  the  management  of  the  second  stage  of  labor. 

The  patient  lies  upon  the  side  toward  which  the  fetal  back 
is  directed.  In  multiparas,  if  the  membranes  fail  to  rupture 
after  full  dilatation  of  the  os,  the  obstetrician  may  break 
them  with  the  finger-nail  during  the  interval  between  two 
pains ;  the  water  should  be  allowed  to  escape  slowly.  As  the 
head  descends  to  the  floor  the  perineum  must  be  guarded 
from  laceration;  on  delivery  of  the  head  it  should  be  sup- 
ported until  the  shoulders  emerge,  and  as  the  child  descends 
the  hand  should  be  placed  upon  the  fundus  uteri  t^  maintain 
good  contraction  of  the  uterine  muscle. 

Define  the  third  stage  of  labor,  and  state  how  it  should 
be  managed. 

This  is  the  period  of  placental  expulsion.  Immediately 
after  the  birth  of  the  child  the  uterus  contracts  and  the  pla- 
centa sinks  to  the  lower  uterine  segment.  Here  it  lies  for  15 
to  30  minutes,  when  a  strong  contraction  occurs  and  the  pla- 
centa is  expelled.  The  accoucheur  may,  after  ligation  of  the 
cord,  hasten  this  delivery  of  the  secundines  by  the  applica- 
tion of  Crede's  method.  If  hemorrhage  occurs  or  the  uterus 
fails  to  contract,  fluid  extract  of  ergot  may  be  administered, 
and  a  firm  pad  and  binder  should  be  applied. 

Describe  the  delivery  of  the  placenta  after  the  method 
of  Crede. 

This  consists  in  applying  gentle  rotatory  friction  to  the 
fundus  uteri  until  it  is  felt  to  harden  under  the  influence  of 
a  uterine  contraction ;  the  fundus  is  then  grasped  by  the  hand 
and  compressed,  while  at  the  same  time  pressure  is  made 
downward  and  bnokward  in  the  line  of  the  axis  of  the  par- 


688  OBSTETlilCS  AND  GYNECOLOGY. 

turient   canal.      The    placenta    is    rapidly   expelled   by   this 
process. 

Describe  the  preparation  of  the  bed,  the  woman,  the 
physician  and  the  nurse  for  a  case  of  labor. 

The  bed-linen  should  be  clean,  and  on  the  side  on  which 
the  woman  lies  the  special  temporary  coverings  should  be 
laid.  These  include  a  large  pad,  a  clean  sheet,  and  a  rubber 
blanket.  These  are  removed  after  delivery  is  accomplished. 
The  woman,  as  soon  as  labor  begins,  is  given  a  full  bath,  and 
the  external  genitalia  are  cleansed  with  green  soap  and  alco- 
hol. A  clean  garment  is  worn,  and  this  is  rolled  up  above 
the  hips  to  prevent  soiling.  She  is  covered  with  a  clean  sheet. 
The  physician  and  nurse  disinfect  themselves  according  to 
the  accepted  methods  of  aseptic  surgery. 

Give  the  causes  of  separation  of  the  placenta.  State 
how  the  placenta  normally  presents  at  the  os  uteri.  De= 
scribe  the  treatment. 

It  is  probable  that  the  main  cause  of  placental  separation 
is  a  diminution  in  the  area  of  placental  attachment  due  to  the 
excessive  uterine  contraction.  Another  view  is  that  there 
occurs  a  partial  central  detachment  of  the  placenta,  with  sub- 
sequent retroplacental  hemorrhage.  The  separation  does  not 
occur  until  the  beginning  of  the  third  stage  of  labor.  The 
placenta  once  separated  is  expelled  to  the  os  uteri  by  passing 
through  and  inverting  the  membranes  which  drag  after  it; 
the  body  of  the  placenta  bulges  forward  in  a  spherical  form. 
Duncan's  theory  is  that  the  placenta  slides  down  the  lower 
uterine  segment  edgewise.  The  treament  of  placental  separ- 
ration  is  expulsion  by  Crede's  manipulation. 

What  is  the  management  of  retained  placenta? 

Retained  placenta  is  quite  distinct  from  adherent  placenta. 
The  former  means  a  resting  of  the  detached  placenta  in  the 
temporarily  paralyzed  lower  uterine  segment.  It  is  a  harm- 
less condition,  and  is  treated  by  Crede's  expression.  Adhe- 
rent placenta  is  one  that  is  partially  detached,  but  remains 


OBSTETRICS  AND  GYNECOLOGY.  689 

adherent  at  points  to  the  original  site  of  placental  attach- 
ment. It  causes  post-partum  hemorrhage,  and  requires  imme- 
diate manual  extraction. 

How  should  the  first  examination  be  made  at  the  bed= 
side  of  a  woman  in  labor? 

The  object  of  the  examination  is  to  determine  the  position 
and  presentation  of  the  child,  its  condition,  the  progress  of 
the  labor,  the  size  of  the  maternal  pelvis  and  the  condition 
of  the  soft  structures  of  the  parturient  canal.  The  abdomen 
is  first  palpated  and  ausculted,  the  patient  lying  on  her  back. 
A  vaginal  examination  is  then  made  with  the  patient  in  the 
left  lateral  recumbent  posture.  The  finger  is  retained  against 
the  membranes  until  the  patient  has  had  a  pain  in  order  that 
the  efficiency  of  the  pains  may  be  determined. 

What  is  the  perineum?  How  is  it  endangered  in  labor, 
and  how  should  it  be  protected? 

The  perineum  is  the  pelvic  floor,  composed  mainly  of  mus- 
cles and  fibrous  tissues.  The  main  muscle  is  the  levator  ani, 
a  large  butterfly-shaped  muscle,  which  affords  the  chief  sup- 
port to  the  pelvic  viscera.  As  the  head  descends  it  impinges 
on  the  perineum  and  stretches  it;  not  infrequently  serious 
lacerations  result  in  consequence  of  too  precipitate  delivery, 
disproportion  betwen  the  head  and  vulvar  orifice,  or  imper- 
fections in  the  mechanism  of  labor.  There  are  various  means 
of  protecting  the  floor  in  labor.  The  head  may  be  retarded 
by  Hohl's  method,  which  consists  in  pressing  the  thumb 
against  the  occiput  above  and  the  index  and  middle  fingers 
posteriorly  against  that  portion  of  the  head  nearest  the  four- 
<"het.  The  forceps  may  be  applied  and  the  movement  of  the 
head  controlled.  Ixitfien's  metiiod  of  elevating  the  head  and 
Olshausen's  method  of  rectal  expression  are  both  valuable. 

What  is  cpisiotomy,  and  when  is  such  interference  in- 
dicated? 

Episiotomy  is  the  making  of  a  lateral  incision  of  the  vulva 
for  the   purpose  of   relieving  vulvar  and   perineal   tension. 
44 


690  OBSTETRICS  AND  GYNECOLOGY. 

The  incisions  are  made  during  the  height  of  a  pain  upon  the 
mucosa  just  within  the  vulvar  cleft,  and  are  from  %  ^  % 
inch  long  and  14  i^ch  deep.  The  operation  should  not  be 
performed,  simple  perineal  laceration  being  preferable. 

How  should  laceration  of  the  perineum  occurring  dur= 
ing  labor  be  treated? 

By  immediate  suturation  if  the  tear  be  over  I/2  inch  long. 
Simple  tears  of  the  fourchet  do  not  require  suturing.  Inter- 
nal tears  of  the  sulci  and  tears  involving  the  sphincter  require 
immediate  repair.  If  the  tear  is  a  simple  median  tear,  and 
the  tissues  are  severely  bruised,  a  primary  perineorrhaphy 
may  not  prove  successful. 

Give  the  causes  and  treatment  of  laceration  of  the  cer= 
vix  uteri. 

Abortion  or  miscarriage  when  the  cervix  is  still  rigid;  pre- 
cipitate delivery,  especially  if  the  woman  be  on  her  feet; 
oversize  of  the  fetal  parts;  instrumental  delivery,  the  head 
not  yet  having  escaped  from  the  uterus.  If  there  is  no  hem- 
orrhage from  the  tear  nothing  should  be  done.  If  the  circular 
artery  has  been  cut  a  suture  must  be  introduced  at  once. 

Give  the  rules  for  administering  anesthetics  in  labor, 
stating  when  they  are  indicated. 

No  anesthetic  is  required  in  a  normal  labor  until  the  head 
is  down  on  the  perineum ;  it  is  then  well,  if  the  pains  be  severe 
and  the  patient  suffering  unduly,  to  administer  a  few  drops 
of  ether  or  chloroform,  not  sufficient  to  arrest  the  uterine 
contraction,  but  enough  to  dull  the  pain.  In  all  operative 
procedures  full  anesthesia  will  be  required.  In  puerperal 
eclampsia  during  the  convulsions  chloroform  should  be  ad- 
ministered; also  in  the  spasms  of  major  chorea. 

State  the  effects  of  anesthetics  on  the  os  uteri,  cervix 
uteri,  abdominal   muscles,  perineum  and  child. 

If  the  anesthesia  be  complete  the  cervix,  os  and  perineum 
become  relaxed ;  all  voluntary  motion  ceases,  and  the  rigidity 


OBSTETRICS  AND  GYNECOLOGY.  691 

of  the  part  is  overcome.  A  certain  amount  of  fetal  asphyxia 
results  in  profound  maternal  anesthesia.  The  labor  is  neces- 
sarily protracted,  since  the  uterine  contractions  are  largely 
or  completely  abolished. 

What  are  the  antiseptic  measures  to  be  employed  in  the 
care  of  a  case  of  labor?  Define  the  terms  asepsis  and 
antisepsis,  and  give  their  proper  application  in  the  lying= 
in  chamber. 

Asepsis  means  absence  of  septic  matter,  or  freedom  from 
infection.  Antiseptfis  means  exclusion  of  the  germs  that 
cause  putrefaction  or  infection.  As  applied  to  labor  it  means 
the  thorough  cleanliness  of  the  patient,  bed,  room,  water, 
instruments,  dressings,  clothing,  physician  and  nurse.  It  in- 
cludes the  use  of  antiseptic  agents,  such  as  carbolic  acid, 
mercuric  chloride,  creolin,  lysol,  and  the  like.  It  includes  for 
some  the  use  of  rubber  gloves  and  the  exclusion,  as  far  as 
possible,  of  the  vaginal  examination. 

What  would  contraindicate  the  use  of  anesthetics  in 
labor? 

Grave  renal  disease  and  any  severe  pulmonary  affection. 

What  preliminary  preparations  are  necessary  for  thei 
safe  conduct  of  labor? 

The  nurse  should  have  on  hand  aseptic  dressings,  anti- 
septic agents,  sterile  water,  hemostatic  remedies,  as  gauze, 
ergotin  and  hot  water,  bichloride  tablets,  creolin  or  lysol, 
chloroform  to  meet  an  eclamptic  seizure,  obstetric  forceps, 
and  whatever  else  may  be  needed  to  meet  any  emergency. 

What  are  the  dangers  to  the  mother  during  the  second 
stage  of  labor,  and  how  can  they  be  minimized? 

The  dangers  are  uterine  inertia,  with  prolonged  pressure 
of  the  fetal  head  upon  the  maternal  tissues,  which  might 
result  in  a  slough;  the  onset  of  eclampsia;  rupture  of  the 
uterus  from  obstruction ;  laceration  of  the  cervix  and  peri- 
neum from  disproportion  between  the  head  and  vulvar  orifice, 


692  OBSTETRICS  AND  GYNECOLOGY. 

or  from  precipitate  labor;  hemorrhage  from  premature  sepa- 
ration of  the  placenta;  apoplexy  or  syncope;  rupture  of 
varicose  veins. 

What  are  the  uses  and  dangers  of  ergot  in  obstetric 
practice? 

The  routine  administration  of  ergot  is  to  be  condemned. 
It  should  be  employed  in  uterine  exhaustion  and  inertia 
during  the  late  second  and  third  stages  of  labor  and  after 
delivery  has  been  completed.  If  given  too  early  it  may  cause 
an  irregular  hour-glass  contraction  of  the  uterus,  with  reten- 
tion of  placenta,  clots,  membranes,  or  debris.  It  has  a  re- 
tarding influence  upon  the  development  of  the  milk.  It  may, 
if  given  early,  cause  fetal  asphyxia  from  tetanic  uterine  con- 
traction. It  also  increases  the  danger  of  cervical  and  peri- 
neal lacerations. 

State  under  what  circumstances  the  vaginal  douche  may 
be  employed  before,  during,  and  after  labor.  Give  the 
technic. 

Unless  the  patient  be  already  infected,  as  from  gonorrhea, 
a  vaginal  douche  should  not  be  given  before  labor,  in  order 
to  avoid  introduction  of  germs  with  the  nozzle  of  the  syringe 
and  the  washing  away  of  the  normal  vaginal  secretion.  Dur- 
ing labor  a  douche  is  given  only  when  there  is  a  profuse 
gonorrheal  discharge  or  when  some  obstetric  operation  is 
about  to  be  performed.  After  normal  labor  no  douche  is  re- 
quired as  a  rule.  If  there  has  been  much  manipulation  of 
the  parts,  or  version  or  other  operation  has  been  performed, 
one  douche  should  be  given,  mercuric  chloride  1-2000  being 
employed.  If  the  lochia  become  offensive  at  any  time,  vag- 
inal douching  should  be  begun  at  once. 

Describe  the  duties  of  the  accoucheur  during  normal 
labor. 

He  is  to  act  simply  as  an  overseer.  Examination  should 
not  be  made  too  freely;  only  often  enough  to  note  a  satisfac- 
tory progress  of  the  labor.    During  the  second  stage  he  should 


OBSTETRICS  AND  GYNECOLOGY.  693 

regulate  the  descent  of  the  head,  institute  measures  to  pre- 
serve the  perineum,  support  the  head  after  delivery  until  the 
shoulders  are  born,  attend  to  the  mouth  and  eyes  of  the  child, 
ligate  the  cord,  and  superintend  the  discharge  of  the  secun- 
dines.  He  should  see  that  uterine  relaxation  does  not  occur, 
and  after  the  patient  has  been  cleaned  he  should  apply  the 
pad  and  binder.  He  should  see  that  the  proper  toilet  for  the 
baby  is  made. 

What  care  does  the  mother  require  after  labor? 

She  should  be  covered  to  prevent  chilling  and  shock.  She 
should  be  cleaned  as  soon  as  possible,  and  the  proper  occlu- 
sive dressing  of  the  vulva  applied  and  secured  to  the  abdom- 
inal binder.  The  bed  should  be  made,  and  clean  clothing  for 
it  and  the  patient  be  provided.  If  there  is  a  tendency  to 
relaxation  of  the  uterus,  ergot  should  be  administered.  The 
head  should  be  kept  low  and  visitors  excluded.  The  visits 
should  be  made  at  suitable  intervals,  and  careful  watch  kept 
of  the  pulse,  temperature,  discharge  and  breasts.  The  prog- 
ress of  involution  should  be  noted.  The  bowels  should  be 
opened  by  the  third  day  and  the  proper  diet  instituted. 

What  is  involution?  Define  subinvolution.  How  long 
a  time  is  usually  required  for  involution,  how  may  it  be 
promoted,  and  what  causes  may  operate  to  delay  or  pre- 
vent it? 

By  involution,  as  applied  to  the  uterus,  is  meant  the  retro- 
gressive change  undergone  by  that  organ  after  parturition, 
by  which  it  returns  to  its  normal  weight  and  condition.  It 
is  brought  about  mainly  by  a  rapid  fatty  degeneration  of  the 
hypertrophied  muscular  tissue.  It  is  completed  in  six  weeks, 
and  is  favored  by  rest  in  bed,  the  repair  of  cervical  and  peri- 
neal lacerations,  the  prevention  of  uterine  displacements,  and 
the  nursing  of  the  child.  It  is  delayed  by  early  rising,  bottle- 
feeding  of  the  baby,  neglect  of  the  cervix,  uterus  and  peri- 
neum, and  an  early  resumption  of  household  duties.  Subin- 
volution is  a  failure  of  the  uterus  to  return  to  its  normal  size. 


694  OBSTETRICS  AND  GYNECOLOGY. 

What  are  after=pains?  State  their  cause  and  give  the 
treatment. 

After-pains  are  irregular  and  painful  contractions  of  the 
uterus  produced  by  efforts  on  the  part  of  that  organ  to  expel 
clots  or  shreds  of  membrane ;  they  indicate  a  partial  relaxa- 
tion of  the  uterine  tissue,  and  are  more  common  in  multiparas. 
They  are  relieved  by  pressure,  and  are  followed  by  the  dis- 
charge of  clots.  The  treatment  consists  in  the  administration 
of  opiates  and  fluid  extract  of  ergot,  embrocations  of  chloro- 
form and  belladonna  liniments  or  a  hypodermic  injection  of 
morphine. 

What  general  directions  should  be  observed  in  passing 
the  catheter  on  a  patient  during  the  puerperal  state? 

Absolute  cleanliness  of  the  meatus  and  vestibule,  as  well  as 
of  the  catheter,  to  prevent  cystitis.  The  parts  should  be 
bathed  in  mercuric  chloride  1-5000,  and  the  patient  should 
not  be  catheterized  oftener  than  once  in  eight  hours. 

What  changes  occur  in  the  fetal  circulation  at  birth? 

With  the  stopping  of  the  feto-placental  circulation- there 
occurs  a  closure  of  the  foramen  ovale,  the  Eustachian  valve 
atrophies,  and  the  ductus  venosus  and  ductus  arteriosus  close 
and  atrophy ;  the  pulmonary  circulation  increases  at  once  and 
becomes  as  in  the  adult  individual. 

What  indications  of  premature  birth  can  be  determined 
in  the  infant? 

Undersize  of  the  infant;  the  nails  do  not  project  over  the 
finger-ends;  there  may  be  some  lanugo  present,  and  there  is 
an  excess  of  vernix  caseosa;  the  face  is  senile  and  wrinkled, 
and  the  development  of  the  limbs  imperfect;  there  is  a  ten- 
dency to  subnormal  temperature. 

How  soon  after  the  birth  of  the  child  should  the  um= 
bilical  cord  be  ligated,  and  describe  your  method  of  pro= 
cedure?     How  should  the  umbilicus  be  managed? 

The  cord  should  be  ligated  only  after  the  pulsations  have 


OBSTETRICS  AND  GYNECOLOGY.  695 

entirely  ceased.  A  small-sized  tape  should  be  used,  and  the 
cord  tied  about  two  inches  from  the  umbilicus,  a  surgeon's 
knot  being  used.  It  may  be  necessary  in  very  thick  cords  to 
"strip"  the  cord  so  as  to  remove  the  excess  of  Wahrton's 
jelly.  The  stump  and  umbilicus  should  be  thickly  dusted 
with  a  powder  of  salicylic  acid  1  part  and  starch  4  parts,  and 
then  covered  with  salicylated  cotton,  through  which  the  cord 
is  passed.     The  whole  is  then  supported  by  the  binder. 

Describe  the  care  of  the  infant  during  the  first  24  hours 
after  birth. 

After  the  establishment  of  respiration  and  the  severing  of 
the  cord  the  baby  should  be  given  a  bath.  The  vernix  caseosa 
must  be  removed  by  rubbing  with  sweet  oil.  Castile  soap 
and  warm  water  are  used  in  cleansing,  and  care  must  be 
taken  not  to  irritate  the  delicate  skin  by  rubbing.  Diapers 
must  be  changed  hourly,  and  plenty  of  talcum  powder  dusted 
on  the  body  to  prevent  chafing.  The  breast  should  be  given 
the  baby  every  four  hours.  In  this  way  it  learns  to  nurse, 
consumes  the  colostrum,  whereby  the  meconium  will  be  ex- 
pelled, and  by  reflex  action  causes  firmer  uterine  contraction. 

Describe  the  immediate  care  of  the  new-born  child  when 
for  any  reason  the  mother  cannot  nurse  it.  Give  the  rules 
for  artificial  feeding. 

The  new-born  baby  does  not  need  food  for  the  first  24-26 
hours.  It  may  be  given  a  spoonful  of  water  now  and  then, 
and  if  it  seems  hungry  it  may  be  given  two  or  three  spoon- 
fuls of  a  mixture  of  condensed  milk  and  water  1  part  to  12. 
If  it  becomes  necessary  to  feed  the  baby  from  the  bottle  the 
latter  must  be  kept  absolutely  clean,  and  a  milk-preparation 
of  suitable  strength  should  be  given.  Oerms  may  be  de- 
stroyed by  Pasteurization.  The  preparation  usually  employed 
consists  of  condensed  milk  1  part,  boiled  water  12  parts, 
cream  1  part,  and  limewnter  1  part.  The  baby  should  be  fed 
every  2  to  2Vi>  hours  during  the  first  month.  The  nursing 
should  consume  from  15  to  20  minutes. 


696  OBSTETRICS  AND  GYNECOLOGY. 

What  instructions  should  be  given  a  primipara  in  re- 
gard to   lactation? 

She  should  be  instructed  as  to  the  frequency  of  nursing 
and  care  of  the  nipple.  Every  2  to  2i/2  hours  by  the  clock 
is  often  enough  for  the  feedings,  and  after  the  nursing  the 
nipple  should  be  bathed  in  warm  water,  thoroughly  dried 
with  a  soft  towel  or  lint,  and  anointed  with  sweet  oil.  The 
oil  should  be  removed  before  the  nipple  is  given  to  the  infant 
at  the  next  feeding. 

How  soon  after  parturition  should  a  woman  men= 
struate? 

If  she  nurse  her  baby,  menstruation  does  not  normally 
return  until  the  ninth  month.  An  early  appearance  of  the- 
menstrual  flow  usually  indicates  subinvolution  of  the  uterus 
or  cervical  laceration. 

What  is  the  puerperal  state? 

The  puerperal  state  or  puerperium  is  the  period  following 
the  delivery  of  the  placenta,  in  which  the  processes  of  involu- 
tion are  being  carried  on.  It  is  characterized  by  rapid  dimin- 
ution in  the  size  of  the  uterus  and  vagina,  decrease  in  the 
pelvic  circulation,  and  lessening  in  the  quantity  of  blood 
circulating  in  the  body. 

What  are  the  most  frequent  complications  of  the  puer= 
peral  period? 

Infection  of  the  birth-canal,  subinvolution,  inflammation 
and  abscess  of  the  mammary  gland,  postpartum  hemorrhage, 
and  constipation. 

How  should  a  case  of  labor  be  conducted  to  avoid  puer- 
peral infection?  What  are  the  sources  of  septic  infection 
in  the  puerperal  state,  and  what  would  be  the  proper 
management  if  infection  should  occur? 

Thorough  asepsis  of  the  woman,  bed,  surroundings,  physi- 
cian and  nurse,  as  already  delineated,  must  be  insisted  upon. 
The  hands  of  the  physician  and  nurse,  the  water  employed. 


OBSTETRICS  AND  GYNECOLOGY.  69T 

and  the  instruments  are  the  chief  sources  of  danger.  Should 
infection  occur,  the  vagina  and  uterus  should  be  well  douched 
with  mercuric  chloride  1-2000-4000,  and  the  uterus  curetted 
with  a  dull  curet  to  remove  decaying  fragments  of  placenta 
and  membranes.  This  will  generally  be  sufficient  for  local 
treatment.  Internally,  quinine,  stimulants  and  strychnine^ 
must  be  administered.  The  graver  forms  of  puerperal  sepsis 
require  special  courses  of  treatment. 

Describe  the  proper  method  of  delivering  an  adherent 
placenta  at  term. 

The  hand,  which  should  be  aseptic,  must  be  immediately 
introduced  into  the  uterine  cavity  to  the  fundus,  following 
the  umbilical  cord  to  the  placental  site.  The  placenta  should 
be  grasped  and  the  adherent  portions  pinched  off  rapidly. 
The  external  hand  grasps  the  uterine  fundus  and  the  internal 
hand  is  expelled  by  the  uterine  contractions.  A  hot  douche, 
intra-uterine,  must  then  be  given,  and  ergot  administered  by 
the  mouth  or  hypodermatically.  Firm  uterine  contractions 
must  be  secured  before  the  patient  is  left. 

How  would  you  treat  asphyxia  in  the  new=born  child? 
What  are  its  causes  and  symptoms? 

The  causes  of  asphyxia  neonatorum  are  syphilitic  stenosis 
of  the  vessels  of  the  cord  and  placenta,  abnormality  of  the 
heart  or  great  ves.sels,  early  separation  of  the  placenta,  undue 
pressure  upon  the  cord,  sudden  maternal  death,  renal  in- 
adequacy, and  grave  maternal  lung  di.sea.se.  The  condition 
appears  in  two  forms,  viz.,  asphyxia  livida  and  asphyxia 
pallida.  ,  In  the  former  the  baby  is  blue  or  livid,  there  are 
irregular  gasping  efforts,  the  heart-beats  are  strong,  and  the 
reflexes  are  preserved.  In  the  pale  variety  respiration  is 
altogether  abolished,  the  surface  is  pale,  the  heart-sounds  are 
weak  and  irregular,  and  the  reflexes  are  absent.  The  treat- 
ment consists  in  early  ligation  of  the  cord,  suspension  of  the 
child  by  the  feet,  cleansing  of  the  throat  and  mouth  by  the 
finger,  slapping  the  back  aud  buttocks,  the  pouring  of  water 


698  OBSTETBICS  AND  GYNECOLOGY. 

or  ether  on  the  epigastrium,  and  in  the  pronounced  cases  the 
emplo;ynnent  of  some  form  of  artificial  respiration,  notably  the 
methods  of  Dew,  Laborde,  Schultze  and  Prochownick.  Occa- 
sionally mouth-to-mouth  insufflation,  catheterization  of  the 
larynx,  or  tracheotomy  may  be  required. 

Describe  a  method  of  resuscitation  of  the  new=born. 

Dew's  method  is  excellent.  The  infant  is  grasped  in  the 
left  hand  in  such  a  manner  that  the  neck  rests  between  the 
thumb  and  forefinger  and  the  head  hangs  over  in  the  position 
of  full  extension ;  the  upper  portion  of  the  back  rests  in  the 
palm  of  the  hand,  while  the  remaining  fingers  are  inserted 
into  the  left  axilla.  The  knees  are  grasped  by  the  right  hand, 
the  right  knee  resting  between  the  thumb  and  forefinger,  the 
left  knee  between  the  index  and  middle  fingers,  and  the  thighs 
in  the  palm  of  the  hand.  The  right  hand  depresses  the  body 
to  favor  inspiration,  while  to  secure  expiration  the  movement 
is  reversed  and  the  child  doubled  upon  itself. 

What  are  the  results  of  subinvolution  of  the  uterus, 
and  what  is  its  treatment? 

Subinvolution  of  the  uterus,  if  not  corrected,  results  in  a 
chronic  endometritis,  retrodisplacement,  and  subsequent  pro- 
lapse of  the  uterus  from  increased  specific  gravity,  and  the 
development  of  a  chronic  invalidism.  The  treatment  consists 
in  the  retention  of  the  uterus  in  its  normal  position  by  means 
of  a  pessary,  curettage  of  the  uterus,  suturation  of  all  cervical 
and  perineal  lacerations,  and  the  administration  of  tonics, 
ergot  and  thyroid  extract. 

How  would  you  recognize  retention  of  urine  during 
labor  and  how  after  labor?  Minutely  describe  the  treat= 
ment  that  should  be  employed  in  each  case. 

Retention  of  urine  during  labor  is  exceedingly  uncommon. 
It  might  result  from  an  uncorrected  retrodisplacement  of  the 
uterus  that  has  gone  on  to  sacculation.  In  such  a  case,  if 
catheterization  of  the  bladder  by  the  prostatic  catheter  fails, 
suprapubic  puncture  of  the  bladder  would  be  required.     Re- 


OBISTETIUCS  AND  GYNECOLOGY.  699 

tention  of  urine  after  labor  is  not  uncommon.  It  is  char- 
acterized by  inability  on  the  part  of  the  patient  to  urinate, 
severe  pain  in  the  bladder,  and  the  development  of  a  cysi'.e 
tumor  over  the  symphysis,  which  presents  dullness  on  percus- 
sion. The  treatment  consists  in  aseptic  catheterization,  with 
withdrawal  of  one-half  to  three-fourths  of  the  vesical  con- 
tents, in  order  to  avoid  syncope. 

Describe  the  technic  of  intra=uterine  irrigation  and  state 
when   its  employment  is  justifiable. 

Intra-uterine  irrigation  is  required  only  after  some  int.'a- 
uterine  manipulation,  as  the  performance  of  version,  manual 
extraction  of  the  placenta,  or  high  forceps  application,  or  in 
case  puerperal  sepsis  has  developed.  The  technic  consists  iu 
antiseptic  douching  of  the  vagina  and  vulva,  followed  by  the 
introduction  to  the  uterine  fundus  of  the  two-way  catheter. 
Mercuric  chloride  1-4000,  creolin,  lysol  or  sterile  water  may 
be  employed.  The  douching  may  be  resorted  to  once,  twice 
or  three  times  daily,  according  to  the  gravity  of  the  patient's 
condition. 

Mention  the  pathogenic  bacteria  that  invade  the  vagina, 
and  state  how  the  vagina  is  normally  protected  from  them. 

A  number  of  pathogenic  germs  have  been  discovered  in  the 
vagina.  The  mast  common  are  the  streptococcus  pyogenes, 
staphylococcus  pyogenes  aureus,  staphylococcus  pyogenes 
albus,  bacterium  coli  commune,  bacillus  pyocyaneus,  bacillus 
pyogenes  fa?tidus,  and  others.  There  normally  exist  in  the 
vagina  a  large  number  of  long-rod  bacilli  known  as  Doder- 
lein's  bacilli.  These  .secrete  an  acid  which  destroys  patho- 
genic germs. 

Define  puerperal  sepsis,  and  state  how  to  prevent  it  and 
how  to  overcome  it.     What  is  auto-infection? 

Puerperal  sepsis  is  the  infection  of  the  puerperal  woman 
by  pathogenic  genns.  It  may  be  prevented  by  careful  atten- 
tion to  the  laws  of  asepsis  and  antisepsis.  If  septic  infection 
developed  it  should  be  combated  in  the  manner  already  de- 


7D0  OBSTETRICS  AND  GYNECOLOGY. 

scribed.  Auto-infection  of  the  puerperal  woman  is  a  rare 
form  of  sepsis,  in  which  the  germs  are  already  in  her  system 
before  the  onset  of  labor,  and  become  active  immediately 
after  parturition. 

State  the  causes,  pathology,  symptoms,  treatment  and 
sequelae  of  puerperal  phlebitis. 

Puerperal  phlebitis  is  a  rare  form  of  puerperal  sepsis 
originating  in  the  sinuses  of  the  uterus.  The  germs  invade 
the  clots  in  the  mouths  of  the  sinuses;  these  quickly  liquefy, 
and  give  rise  to  hemorrhages  and  to  emboli,  which  are  carried 
to  remote  portions  of  the  body.  This  may  result  in  instant 
death  or  in  pyemia,  with  septic  pneumonia,  paralysis,  and 
other  serious  consequences.  The  treatment  consists  in  the 
general  treatment  of  puerperal  sepsis,  with  avoidance  of  all 
local  interference  other  than  the  introduction  of  a  gauze  tam- 
pon to  control  the  hemorrhage. 

How  would  you  diagnose  puerperal  metritis,  and  what 
methods  would  you  employ  in   its  treatment? 

Puerperal  metritis  is  a  late  septic  inflammation  of  the 
uterine  muscle.  It  is  characterized  by  an  offensive  lochial 
discharge,  which  contains  fragments  of  necrotic  tissue  and 
detached  portions  of  muscular  fibers  that  have  sloughed  from 
the  uterine  wall.  The  uterus  is  large,  soft,  boggy  and  sen- 
sitive. There  is  danger  of  perforation  of  the  uterine  walls 
and  the  development  of  general  peritonitis.  Uterine  phlebitis 
may  also  develop,  with  a  resulting  general  pyemia.  The 
treatment  consists  in  hysterectomy  performed  with  thorough 
asepsis. 

Define  hysterectomy,  and  state  when  it  is  applicable  in 
obstetric  complications. 

Hysterectomy  is  excision  of  the  uterus.  It  is  indicated  in 
puerperal  metritis,  extensive  involvement  of  the  broad  liga- 
ments, and  when  tubal  and  ovarian  infection  is  associated 
with  profuse  hemorrhage  from  the  uterus. 


OBSTETRICS  AND  GYNECOLOGY.  701 

What  is  phlegmasia  alba  dolens?  Give  the  varieties, 
symptoms  and  treatment. 

Phlegmasia  alba  dolens  or  ^^ milky  leg"  is  a  peculiar  late 
manifestation  of  puerperal  sepsis,  in  which  there  occurs  a 
thrombosis  of  the  iliac  or  femoral  veins  on  one  side,  usually 
the  left,  with  an  immense  edema  of  the  affected  limb,  which 
presents  a  characteristic  white  or  milky  appearance.  In  the 
pJilebitic  or  thrombotic  form  the  edema  first  appears  below 
at  the  ankle,  the  disease  occurring  as  a  sequel  of  uterine 
phlebitis,  coagula  being  carried  from  the  placental  site  into 
the  hypogastric  veins.  In  the  cellulitic  form  the  disease 
occurs  as  a  result  of  a  direct  extension  of  an  inflammatory 
process  from  the  uterus  through  the  broad  ligament  and  pelvic 
cellular  tissue,  the  exudate  occluding  the  iliac  veins.  The 
symptoms  are  pains  in  the  affected  limbs  along  the  course  of 
the  femoral  vein,  rapid  pulse,  elevation  of  temperature, 
cramp-like  pains  in  the  calf,  edema,  and  extreme  pallor  of  the 
limb,  or,  in  a  certain  proportion  of  the  cases,  bluing  of  the 
leg;  abscess  or  gangrene  may  follow.  The  treatment  consists 
in  the  administration  of  stimulants  and  tonics,  disinfection 
of  the  birth-canal,  gentle  laxatives,  and  immobilization  of  the 
limb,  which  should  be  elevated  and  kept  warm.  Anodyne 
poultices,  and  later  ichthyol  and  belladonna  ointments,  may 
be  applied.  Abscesses  should  be  opened,  and  if  gangrene 
occurs  amputation  is  necessary. 

What  is  postpartum  hemorrhage?  State  the  causes  and 
varieties,  and  give  the  treatment,  including  prophylaxis. 

Postpartum  hemorrhage  or  "fioodiiig"  is  hemorrhage  oc- 
curring at  any  time  during  the  24  hours  after  parturition. 
It  may  be  pnmary,  at  the  time  of  delivery,  or  secondary, 
when  it  occurs  after  contraction  of  the  uterus  has  been 
secured.  Its  causes  are  retention  of  placental  debris,  adher- 
ent placenta,  uterine  inertia,  or  severe  laceration  of  the  lower 
birth-canal.  The  symptoms  are  free  escape  of  blood,  pallor, 
lunning  pulse,  restlessness,  and  coma.  The  prophylactic 
treatment  includes  the  use  of  strychnine  and  tonics  during 


702  OBSTETRICS  AND  GYNECOLOGY. 

the  last  trimester  of  pregnancy,  and  at  the  time  of  labor  the 
avoidance  of  extreme  exhaustion,  and  if  the  uterus  be  atonic 
the  administration  of  a  dram  of  ergot  as  soon  as  the  head  is 
bom.  The  active  treatment  consists  in  the  immediate  removal 
of  all  clots  and  debris,  the  application  of  Grade's  manipula- 
tion, the  hypodermic  injection  of  ergot  or  ergotin,  the  intra- 
uterine injection  of  hot  water,  or  the  introduction  of  a  large 
tampon  of  iodoform  or  sterile  gauze.  Herman's  metJiod  of 
continual  manual  compression  of  the  uterus  and  compression 
of  the  abdominal  aorta  may  be  tried  in  extreme  cases.  Trac- 
tion on  the  cervix  with  volsella-forceps  will  often  control  the 
bleeding.  Bleeding  from  the  lower  birth-canal  must  be  con- 
trolled by  the  introduction  of  sutures. 

What  is  a  tampon?  How  is  it  made  and  when  is  it 
properly  used?  What  precautions  are  to  be  observed  in 
its  use? 

A  tampon  is  a  plug  of  cotton,  gauze,  wool  or  oakum  used 
to  stop  some  canal  or  compress  a  bleeding  surface.  It  may 
be  made  by  passing  a  string  around  a  portion  of  the  substance 
used,  or  it  may  consist  of  a  long  strip  of  material  packed  in 
firmly.  It  is  indicated  in  obstetrics  in  excessive  hemorrhage, 
as  from  placenta  prsevia,  relaxation  of  the  uterus,  or  lacera- 
tions of  the  lower  birth-canal.  Care  must  be  taken  to  see 
that  the  material  used  is  thoroughly  aseptic,  and  that  the 
cervix  and  vagina  are  not  so  distended  as  to  give  entrance  to 
air,  whereby  air-embolism  may  be  induced. 

Differentiate  eutocia  and  dystocia.  Mention  important 
varieties  of  the  latter. 

Eutocia  is  normal  or  easy  labor;  dystocia  is  abnormal,  diffi- 
cult, or  painful  labor.  Dystocia  may  consist  in  precipitate, 
retarded  or  obstructed  labor,  or  labor  complicated  by  fetal 
or  maternal  accidents,  or  by  gross  fetal  or  maternal  disease. 
This  includes  hydrocephalus,  malpositions  and  malpresenta- 
tions  of  the  fetus,  eclampsia,  rupture  of  the  uterus,  prolapse 
of   the   cord,   placenta   praevia.    premature  separation   of   the 


OBSTETRICS  AND  GYNECOLOGY.  703 

placenta,  contracted  pelvis,  and  various  other  conditions  on 
the  part  of  the  fetus  and  mother. 

Give  the  causes  of  dystocia  in  the  uterus,  vagina,  pelvis, 
and  vulva. 

In  the  uterus  as  causes  of  dystocia  may  be  mentioned  the 
presence  of  tumors,  double  uterus,  abnormal  placental  attach- 
ment, rupture  of  the  uterus,  and  malpresentations  of  the 
fetus.  In  the  vagina,  septa,  stenosis,  and  tumors;  in  the 
pelvis  the  various  forms  of  contraction  and  bony  and  carti- 
laginous tumors;  in  the  vulva,  hematomata,  stenosis  or  atresia, 
imperforate  hymen  and  tumors. 

Describe  the  difficulties  which  arise  during  labor  from 
malposition  of  the  fetal  head. 

If  the  head  lie  transversely  in  the  superior  strait  it  will 
become  partially  extended,  and  cause  larger  diameters  of  the 
fetal  skull  to_ engage  than  in  vertex  presentations.  This  will 
cause  prolongation  or  absolute  blocking  of  the  labor.  Exces- 
sive moulding  and  disfiguring  of  the  fetal  presentation  will 
follow;  forceps  or  version  may  be  necessitated.  If  the  face 
or  brow  present,  labor  may  become  impossible. 

How  would  you  diagnose  and  manage  a  case  of  occipito- 
posterior  presentation? 

In  this  case  the  vertex  may  be  dii'ected  t-o  the  right  or  to 
the  left  sacro-iliac  synchondrosis,  and  the  sagittal  suture  will 
lie  in  the  right  or  left  oblique  diameter  respectively.  The 
R.  0.  P.  is  the  most  common  of  the  oceipito-posterior  presen- 
tations. The  case  must  be  treated  by  laying  the  woman  upon 
the  side  toward  which  the  fetal  back  is  directed  in  order  to 
secure  full  flexion  of  the  head,  and  thereby  prevent  backwai'd 
rotation  of  the  occiput.  A  fii-m  l)inder  should  be  applied, 
and  (juinine  must  be  administered  and  delivery  accomplished. 
.\s  the  head  rotates  anteriorly,  the  instruments  must  be  with- 
diviwn  and   ri^applied   in   the  new  (^blicpie  dianietei-. 


704  OBSTETRICS  AND  GYNECOLOGY. 

How  would  you  diagnose  and  deliver  an  occiput  in  the 
hollow  of  the  sacrum? 

In  this  case  the  small  fontanel  will  be  felt  in  the  median 
line  posteriorly  and  the  large  fontanel  high  up  anteriorly. 
The  ears  may  be  palpated  to  either  side  in  the  transverse 
diameter.  Labor  will  be  blocked.  Forceps  must  be  applied, 
and  as  traction  is  made  the  handles  must  be  elevated  in  order 
to  overflex  the  head.  When  the  occiput  begins  to  greatly  dis- 
tend the  perineum  and  the  brow  comes  under  the  symphysis, 
the  handles  must  be  carried  downward,  and  the  head  deliv- 
ered with  the  face  emerging  from  under  the  symphysis. 

Describe  in  detail  the  proper  procedure  when  the  head 
is  movable  above  the  brim  of  the  pelvis  but  does  not  en= 
gage. 

There  is  probably  some  degree  of  pelvic  flattening  present. 
If  so,  the  head  will  lie  transversely.  Axis-traction  forceps 
should  be  applied  and  the  head  made  to  engage.  If  this  be 
impossible,  and  the  contraction  of  the  pelvis  is  not  too  great, 
podalic  version  is  indicated.  In  more  extreme  degrees  of 
contraction  Cesarean  section  must  be  performed. 

Give  the  frequency,  causes,  diagnosis,  prognosis,  treat= 
ment  and  dangers  to  the  fetus  in  pelvic  presentations. 

Pelvic  presentations  of  the  fetus  occur  in  about  3  per  cent, 
•of  all  cases  of  labor.  The  causes  of  breech  presentations  are 
reversal  of  the  shape  of  the  fetus  or  of  the  uterine  cavity, 
hydrocephalus,  fibroid  tumors  of  the  uterus,  prematurity  of 
the  fetus,  hydramnios,  fetal  monstrosities,  and  multiple  preg- 
nancy. In  these  cases  the  fetal  head  is  freely  movable  and 
high  up  in  the  abdominal  cavity;  the  fetal  heart-sounds  will 
be  heard  above  the  umbilicus  and  to  either  side.  Vaginal 
examination  shows  an  absence  of  a  hard  and  protuberant  pre- 
sentation ;  the  presentation  is  high  up,  and  the  bag  of  waters 
long  and  finger-like.  If  the  membranes  have  ruptured,  a  dis- 
charge of  meconium  will  be  noted.  The  prognosis  is  serious 
for  the  fetus.     Thirty  per  cent,  of  these  babies  perish  from 


OBSTETRICS  AND  GYNECOLOGY.  705 

asphyxia  or  injury  to  the  head  and  neck  in  delivery.  The 
treatment  consists  in  non-action  until  the  birth  of  the  umbil- 
icus; then  there  must  be  speedy  extraction  of  the  after- 
coming  head  in  order  to  avoid  fetal  death. 

Describe  the  management  of  an  impacted  breech  pre= 
sentation. 

If  the  breech  become  impacted,  attempts  may  be  made  to 
decompose  it  by  Goodell's  method,  viz.,  the  dragging  down 
of  one  leg,  upon  which  traction  is  made.  If  this  does  not 
succeed,  axis-traction  forceps  may  be  applied  over  the  pelvis; 
this  is  a  very  efficient  method.  Other  methods  consist  in  the 
use  of  a  fillet  around  the  waist  and  thighs,  and  in  dead  babies 
the  blunt  hook  over  one  thigh. 

Give  the  frequency,  causes,  mechanism  and  treatment 
of  face  presentation,  L.  M.  A.  position. 

Face  presentation  occurs  in  about  1/2  percent,  of  all  cases 
of  labor.  It  results  from  anything  which  will  prevent  thor- 
ough flexion  of  the  head,  such  as  an  enlarged  thyroid  or 
thymus  gland  or  a  prominent  thorax,  or  anything  that  will 
disturb  the  relationship  existing  between  the  long  axes  of  the 
body  and  head  of  the  fetus,  as  dolichocephalus.  The  mech- 
anism consists  in  full  extension  and  moulding,  descent  of  the 
chin  to  the  pelvic  floor,  anterior  rotation  to  the  symphysis 
under  which  it  lodges,  and  birth  of  the  head  by  a  process  of 
flexion;  the  shoulder  and  hip  then  rotate  from  the  opposite 
side,  and  the  rest  of  the  mechanism  is  the  same  as  in  vertex 
presentations.  If  the  chin  be  anterior  the  labor  will  probably 
be  easy,  since  small  diameters  present.  If  the  head  sticks, 
forceps  may  be  applied  and  the  chin  drawn  down,  after  which 
labor  will  proceed. 

Give  the  diagnosis  of  face  presentation  before  and  after 
rupture  of  the  membranes. 

Before  i-upture  of  tiie  membranes  the  presentation  will  be 
noted  as  high ;  there  is  an  absence  of  the  dome-like  projection 
of  other  head  presentations;  the  features  of  the  face  may  be 
45 


706  OBSTETRICS  AND  GYNECOLOGY. 

detected.  After  rupture  of  the  membranes  the  examining^ 
finger  can  be  introduced  into  the  mouth,  when,  if  the  child 
be  living,  reflex  closure  of  the  gums  will  be  noted. 

How  may  a  face  presentation  be  converted  into  a  vertex 
presentation? 

If  labor  has  not  yet  be^n,  Schatz's  method  of  cephalic 
version,  performed  by  external  manipulation  alone,  may  be 
attempted.  With  one  hand  firm  pressure  is  exerted  against 
the  anterior  portion  of  the  fetal  neck,  while  counter-pressure 
is  made  with  the  opposite  hand  upon  the  occiput ;  at  the  same 
time  an  assistant  pushes  the  breech  in  the  direction  in  which 
the  face  is  looking;  the  head  is  thus  flexed  upon  the  body 
and  the  vertex  caused  to  present.  If  labor  has  already  be- 
gun, and  the  os  is  dilating,  Baudelocque's  method  of  cephalic 
version,  the  "ratchet  method,"  may  be  attempted  under 
anesthesia.  One  hand  is  placed  against  the  face,  and  while 
the  thumb  pushes  the  chin  upward  the  fingers  hook  over  the 
occiput  and  drag  it  down ;  an  assistant  at  the  same  time 
carries  the  breech  over  to  the  side  toward  which  the  face  is 
directed. 

What  is  the  mechanism  of  a  mento=posterior  position, 
and  what  the  complications? 

A  persistent  mento-posterior  position  is  an  absolutely  im- 
possible labor,  and  therefore  there  is  no  mechanism.  For 
labor  to  advance  the  chin  must  strike  the  pelvic  floor.  The 
lateral  height  of  the  pelvis  is  31/2  inches  (9  cm.),  while  the 
length  of  the  fetal  neck  is  only  lyo  inches.  The  posterior 
height  of  the  pelvis  is  5  inches  (12%  cm.).  In  order  for  the 
chin  to  reach  the  floor  in  these  cases  it  would  be  necessary 
for  the  thorax  and  occiput  (18i/^  cm.  or  7  inches)  to  enter 
the  superior  strait  simultaneously.  No  diameter  of  this  stfait 
could  accommodate  such  a  bulk.  The  uterus  becomes  tetanic 
in  action,  the  head  and  shoulders  become  impacted,  the  child 
perishes,  and  the  mother  is  exposed  to  the  danger  of  uterine 
rupture. 


OBSTETRICS  AND  GYNECOLOGY.  707 

How  should  forceps  be  applied  in  a  case  of  face  pre= 
sentation? 

In  the  mento-occipital  diameter,  the  chin  being  in  apposi- 
tion with  the  heel  of  the  bladder;  the  forceps  should  be  used 
only  as  rotators  in  mento-posterior  positions. 

How  would  you  manage  a  brow  presentation? 

A  brow  presentation  is  an  absolutely  impossible  case  of 
labor.  The  occipito-mental  diameter  of  the  fetal  head,  131/^ 
cm.,  attempts  to  engage,  but  can  find  no  accommodation  in 
the  superior  strait.  The  treatment  consists  in  the  perform- 
ance of  cephalic  version,  bringing  down  the  occiput  and  apply- 
ing forceps.  If  this  be  not  possible,  podalic  version  should 
be  tried.  In  impacted  cases  with  the  child  dead,  craniotomy, 
with  perforation  through  the  bregma,  becomes  necessary. 

How  would  you  treat  a  case  of  lateral  presentation? 

Lateral  presentations  of  the  head,  including  the  parietal 
eminence  or  the  ear,  should  be  treated  by  manual  replacement, 
converting  the  presentation  into  a  true  vertex  presentation. 
If  this  be  impossible  forceps  may  be  applied  or  podalic  ver- 
sion performed. 

Make  a  diagnosis  of  transverse  presentation,  and  state 
how  it  should  be  managed.  Give  the  frequency,  causes, 
mechanism  and  management  of  such  a  case. 

A  transverse,  shoulder  or  trunk  presentation  occurs  in 
about  1/^  per  cent,  of  all  cases  of  labor.  The  causes  are  over- 
size of  the  fetal  head,  overgrowth  of  the  entire  fetus,  fetal 
monstrosities,  mobility  of  the  fetus,  hydramnios,  multiple 
pregnancy,  uterine  deformities,  undue  obliquity  of  the  uterus, 
uterine  and  pelvic  tumors,  placenta  pra^via,  and  traumatism, 
such  as  falls  or  ,iars.  There  is  no  mechanism  for  such  a  case, 
the  labor  being  absolutely  impossible.  The  condition  may  be 
recognized  readily  by  external  palpation,  the  child  lying  at 
right  angles  to  the  long  axis  of  the  maternal  body.  Vaginal 
examination  rovoals  a  high  position  of  the  presentation,  and 
the   shnuldor  or  elbow   may  be   palpated   through    the   mem- 


708  OBSTETRICS  AND  GYNECOLOGY. 

branes.     There  is  but  one  thing  to  do  in  all  transverse  pre- 
sentations, namely,  podalic  version  under  full  anesthesia. 

How  should  a  hand  presentation  be  managed?  What 
course  would  you  pursue  if  you  found  an  arm  projecting 
from  the  vulvar  orifice? 

This  would  indicate  a  cross-birth.  The  arm  should  be  left 
alone,  and  podalic  version  performed.  A  tape  may  be  tied 
around  the  wrist  in  order  to  prevent  extension  of  the  extrem- 
ity during  the  process  of  turning;  if  the  tape  be  held  taut 
the  arm  is  carried  in  front  of  the  face  and  descends  with  the 
shoulders. 

What  are  the  causes  of  precipitate  labor,  what  are  its 
dangers,  and  what  is  the  treatment? 

Precipitate  labor  may  be  caused  by  an  excess  in  the  expul- 
sive power  of  labor  or  a  deficiency  in  the  resistant  powers. 
The  dangers  to  the  fetus  are  asphyxiation  from  rupture  of 
the  cord  or  premature  detachment  of  the  placenta  and  injury 
from  a  fall  upon  the  floor  or  into  a  commode.  The  maternal 
dangers  are  hemorrhage,  fatal  syncope  from  sudden  evacua- 
tion of  the  uterine  contents,  inversion  of  the  uterus,  lacera- 
tion of  the  cervix  or  perineum,  and  post-partum  hemorrhage. 
The  treatment  of  precipitate  labor  consists  in  a  retardation 
of  the  advancing  presentation  in  order  to  avoid  the  fore- 
going accidents.  When  the  head  is  on  the  floor  short  forceps 
may  be  applied  and  the  progress  of  the  head  arrested. 

What  are  the  causes  of  delay  in  labor  (a)  on  the  part 
of  the  mother;  (b)  on  the  part  of  the  child? 

The  maternal  causes  of  delayed  labor  are  uterine  inertia 
and  obstruction  in  the  birth-canal  from  any  cause.  The  fetal 
causes  are  malposition  and  malpresentation,  oversize,  hydro- 
cephalus, fetal  syphilis,  fetal  ascites,  and  other  diseases  caus- 
ing overgrowth  of  organs  or  distension  of  cavities. 

State  the  dangers  and  symptoms  of  a  prolonged  labor. 

The  symptoms  of  prolonged  labor  are  those  of  uterine  in- 


OBSTETRICS  AND  GYNECOLOGY.  709 

ertia  (see  below).  The  dangers  are,  for  the  fetus,  fatal  com- 
pression of  the  brain-centers  and  intra-uterine  respiration, 
with  inspiration  of  liquor  amnii  or  other  substances.  The 
maternal  dangers  are  pressure-necrosis,  the  development  of 
sepsis,  exhaustion  and  death,  and  post-partum  hemorrhage. 

Give  the  causes,  diagnosis  and  management  of  uterine 
inertia. 

Uterine  inertia  is  that  condition  in  which  the  uterine  con- 
tractions are  irregular,  weak  and  ineffectual,  not  sufficing  to 
induce  dilatation  of  the  os  or  expulsion  of  the  fetus.  The 
causes  are  idosyncrasy,  advanced  age  of  the  woman,  multi- 
parity,  emotion,  temporary  paralysis  of  the  uterine  muscles, 
as  from  over-distension,  weakness  of  the  muscle,  and,  any 
cause  preventing  the  hydraulic  action  of  the  liquor  amnii. 
The  symptoms  are  weak,  infrequent  and  irregular  contrac- 
tions, slight  suffering,  and  slow  or  no  advance  of  the  fetal 
presentation.  In  the  first  stage  of  labor  quinine  may  be 
administered  in  large  doses  and  a  firm  abdominal  binder 
applied ;  strj^chnine  during  the  last  weeks  of  pregnancy  has  a 
tendency  to  increase  the  efficiency  of  the  uterine  contraction. 
In  the  second  stage  of  labor  forceps  should  be  applied,  and 
after  the  delivery  of  the  child  ergot  must  be  used  in  large 
doses  to  prevent  post-partum  hemorrhage. 

What  is  the  proper  management  of  rigidity  of  the  os 
uteri  in  labor? 

Rigidity  of  the  cervix  is  common  in  elderly  primiparie  and 
in  thoj-e  suffering  from  uterine  inertia;  it  may  result  from 
cicatrices  and  from  cancerous  involvement  of  the  cervix.  The 
treatment  consists  in  the  administration  of  large  doses  of 
chloral,  hot  vaginal  douches,  anesthesia,  cocaine  to  the  cervix, 
digital  divulsion,  or  incision. 

Give  the  diagnosis  and  treatment  of  hour-glass  contrac- 
tion of  the  uterus. 

Hour-glass  contraction  of  the  uterus  is  an  irregular  ct)n- 
traction  of  the  uterus,  usually  occurring  before  the  escape  of 


710  OBSTETRICS  AND  GYNECOLOGY. 

the  placenta,  which  is  retained  above  the  ring  of  Bandl.  The 
latter  appears  to  be  in  an  abnormal  state  of  contraction. 
Digital  exploration  traces  the  cord  up  to  the  contracted  ring. 
Treatment  consists  in  digital  divulsion  of  the  contracted  por- 
tion, followed  by  removal  of  the  placenta  and  antisepsis  of 
the  cavity. 

Give  the  causes,  symptoms,  diagnosis  and  prognosis  of 
rupture  of  the  uterus  during  labor,  and  state  how  such  an 
accident  should  be  managed. 

The  exciting  causes  of  uterine  rupture  during  labor  are 
some  insuperable  obstruction  to  the  delivery  of  the  child,  mis- 
directed or  injudicious  efforts  at  version,  and  tetanic  action 
of  the  muscle  of  the  upper  uterine  segment  from  the  admin- 
istration of  ergot.  The  predisposing  causes  are  diminished 
tonicity  of  the  uterine  walls,  undue  prolongation  of  labor, 
fatty  degeneration  of  the  uterine  muscle,  or  a  previous  opera- 
tion upon  the  uterus.  The  site  of  the  rupture  is  usually  in 
the  lower  uterine  segment.  The  symptoms  are  sudden,  acute, 
lancinating  pain,  immediate  collapse,  signs  of  internal  hemor- 
rhage, an  anxious  expression,  pallor,  rapid  running  pulse, 
recession  of  the  presenting  part,  the  presence  of  two  distinct 
tumors,  and  the  ability  to  detect  the  rent  by  the  examining 
finger.  The  prognosis  is  grave;  the  maternal  mortality  is  55 
to  60  per  cent.  The  treatment  consists  in  immediate  evacua- 
tion of  the  uterine  contents,  and  if  the  tear  has  not  com- 
pletely perforated  the  uterus  the  patient  may  be  watched 
carefully  for  the  development  of  sepsis.  In  complete  lacera- 
tion an  abdominal  section  must  be  performed  and  the  tear 
sutured  aseptically. 

Make  a  differential  diagnosis  of  intra=uterine  and  extra= 
uterine  hemorrhage. 

In  the  former  there  will  be  noted  either  a  free  escape  of 
blood  per  vaginam  or  a  rapidly  distending  uterine  body, 
associated  with  the  symptoms  of  hemorrhage.  In  the  latter 
the  signs  of  concealed  hemorrhage  will  be  present,  and  vag- 


OBSTETRICS  AND  GYNECOLOGY.  711 

inal  examination  will  reveal  the  presence  of  a  bog^-  mass  in 
the  abdominal  cavity  and  in  Douglass'  cul-de-sac. 

Give  the  diagnosis,  causes  and  treatment  of  pelvic  hemo= 
tocele. 

Pelvic  hematocele  results  generally  from  rupture  of  an 
€xtra-uterine  pregnancy.  It  may  result  from  rupture  of 
varicose  veins  in  the  broad  ligament.  It  is  recognized  by  the 
signs  of  concealed  hemorrhage  and  a  rapidly  increasing  boggy 
mass  in  Douglass'  cul-de-sac.  The  only  treatment  is  abdom- 
inal section  and  ligation  of  the  bleeding  point. 

Name  three  important  forms  of  hemorrhage  occurring 
in  obstetric  practice. 

Antepartum  hemorrhage,  or  that  occurring  in  the  last  tri- 
mester of  pregnancy.  This  may  be  due  to  placenta  prsevia 
or  premature  separation  of  the  placenta.  Intrapartum  hem- 
orrhage is  that  occurring  during  the  progress  of  labor,  as  in 
the  case  of  uterine  rupture  or  inversion  of  the  uterus.  Post- 
partum hemorrhage  is  that  form  occurring  immediately  after 
labor. 

What  is  placenta  praevia?  Name  its  causes,  varieties, 
symptoms,  dangers  and  management. 

Placenta  prcuvia  is  that  condition  in  which  the  placenta  is 
attached  to  the  lower  uterine  segment,  and  presents  in  front 
of  the  fetus.  It  may  be  complete  or  central  {placenta  cetir- 
trails),  lateral,  marginal  and  parietal.  The  cause  of  placenta 
praevia  is  unknown.  It  has  been  said  to  be  due  to  uterine 
subinvolution,  low  fixation  of  the  ovum,  and  downward 
growth  of  the  decidua  reflexa.  There  is  but  one  symptom, 
namely,  free  and  painless  hemorrhage,  occurring  at  decreas- 
ing intervals  and  in  increasing  quantity.  The  dangers  are 
fetal  and  maternal  death  from  asphyxia,  hemorrhage,  air- 
embolism,  and  septic  infection.  The  treatment  consists  in 
rapid  dilatation  of  the  os  and  delivery  of  the  fetus  by  ver- 
sion, or  in  the  marginal  form  the  application  of  the  forceps 
and  rapid  engagement  of  the  head.  In  the  central  variety 
the  hand  must  be  carried  directly  through  the  placenta. 


712  OBSTETRICS  AND  GYNECOLOGY. 

Mention  two  distinct  methods  of  dilatation  of  the  cervix 
uteri  in  obstetric  practice. 

Edgar's  method  consists  in  bimanual  stretching  and  par- 
alyzing of  the  cervical  muscle.  The  index  and  middle  fingers 
of  both  hands  are  introduced  into  the  cervix,  which  is  grad- 
ually but  forcibly  stretched  in  various  directions.  Another 
method  is  the  use  of  bags,  such  as  Barnes'  or  those  of  Cham- 
petier  de  Ribes  and  Voorhees. 

What  are  the  dangers  of  traction  on  the  child  and  on 
the  placenta? 

Traction  on  the  cord  may  cause  premature  separation  of 
the  placenta.  It  may  cause  rupture  of  the  cord  or  avulsion 
of  the  cord  from  the  placenta,  or  it  may  result  in  inversion 
of  the  uterus. 

What  is  inversion  of  the  uterus,  what  its  causes  and 
symptoms,  and  how  is  it  recognized? 

By  this  term  is  meant  a  turning  of  the  uterus  inside  out, 
either  completely  or  in  part.  It  may  occur  spontaneously, 
the  uterine  fundus  or  placental  site  being  temporarily  par- 
alyzed and  sinking  in;  it  may  result  from  traction  on  the 
cord,  the  placenta  not  yet  having  separated ;  or  it  may  follow 
suction  from  close  fitting  of  the  detached  placenta  in  the  lower 
uterine  segment  and  traction  being  made  upon  the  cord. 
Other  causes  are  vigorous  Crede  manipulations  and  violent 
bearing  down  on  the  part  of  the  woman.  The  symptoms  are 
acute  pain,  hemorrhage,  shock,  bearing  down,  and  the  appear- 
ance of  a  tumor  in  the  vagina.  This  may  be  mistaken  for  a 
uterine  polyp,  but  the  surface  of  the  latter  will  be  covered 
with  the  normal  uterine  mucosa,  while  the  inverted  uterus 
will  show  decidual  tissue  and  the  site  of  the  placental  attach- 
ment ;  the  orifices  of  the  Fallopian  tubes  may  also  be  detected. 
The  treatment  of  acute  inversion  consists  in  immediate  re- 
placement, followed  by  the  introduction  of  a  strip  of  gauze 
to  prevent  recurrence. 


OBSTETRICS  AND  GYNECOLOGY.  713 

Give  the  causes,  pathology,  symptoms  and  prognosis  of 
eclampsia  gravidarum,  and  state  the  relative  frequency  in 
primiparae  and  multiparae.     What  is  the  treatment? 

Puerperal  eclampsia  or  puerperal  convulsion  is  a  convul- 
sive or  epileptiform  seizure  appearing  suddenly  in  a  woman 
prior  to,  during  or  shortly  after  labor,  and  characterized  by 
tonic  and  then  clonic  convulsions  of  the  muscles,  with  albu- 
minuria, coma  and  death.  The  great  majority  of  cases  occur 
in  primiparai — about  75  per  cent.  Other  causes  are  heredity, 
climatic  influence,  multiple  pregnaney,  extreme  anemia,  and 
nervous  excitability,  all  acting  as  predisposing  influences. 
The  true  cause  is  the  presence  in  the  blood  of  toxins,  prob- 
ably of  hepatic  origin,  which  cause  a  general  arteriole  con- 
traction ;  as  a  consequence  there  follows  an  anemia  of  the  base 
of  the  brain  and  a  corresponding  cortical  congestion.  The 
symptoms  are  fixing  of  the  eyes,  tonic  contraction  of  the  facial 
muscles  (sardonic  grin),  lividity,  rapid  involvement  of  all 
the  trunk  muscles,  distension  of  the  superficial  veins,  and 
frothing  at  the  mouth.  The  paroxysm  lasts  from  i/^  to  2 
minutes.  It  is  followed  by  increasing  coma  and  a  rise  of 
temperature.  The  urine  becomes  loaded  with  albumin.  The 
prognosis  is  grave;  30  per  cent,  of  the  women  and  50  to  74 
per  cent,  of  the  children  perish.  The  causes  of  maternal 
death  are  asphyxia,  cerebral  apoplexy,  syncope,  pulmonary 
edema,  and  exhaustion.  The  fetus  dies  of  asphyxia.  The 
prophylactic  treatment  is  the  treatment  of  the  kidney  of 
pregnancy.  During  the  attack  chloroform  must  be  admin- 
istered. After  the  spasm,  if  the  patient  be  plethoric,  vene- 
section to  the  amount  of  20-25  ounces  may  be  performed, 
followed  by  the  introduction  of  normal  saline  solution  into 
the  tissues.  Croton  oil  1  to  3  drops,  chloral  hydrate  30  grains 
by  the  rectum,  and  veratrum  viride  15  drops  of  the  fluid  ex- 
tract hypodermically  may  be  administered.  A  hot  pack  aids 
in  the  elimination  of  tlie  poison.  The  uterus  sliould  be  emp- 
tied as  soon  as  possible  in  order  to  still  further  relieve  the 
svstctn. 


714  OBSTETRICS  AND  GYNECOLOGY. 

Give  the  danger=signals  of  impending  eclampsia. 

Rapidly  lessening  amount  of  urates  in  the  urine ;  lessened 
urinary  toxicity,  the  development  of  eye-symptoms,  including 
m^useae  volitantes,  scintillations  and  blindness,  and  neuralgic 
pains  over  the  eyes,  under  the  clavicles  and  in  the  epigastrium. 

In  case  eclampsia  gravidarum  appears  before  the  end  of 
the  eighth  month,  how  should  it  be  managed?  ? 

By  dilatation  of  the  os  and  removal  of  the  child  by  forceps 
or  version.  The  course  of  treatment  already  indicated  should 
be  adopted. 

What  are  the  varieties  of  puerperal  convulsions,  and 
how  are  they  differentially  diagnosed? 

A  puerperal  woman  may  suffer  from  various  convulsive 
seizures,  including  the  true  puerperal  eclampsia.  She  may 
have  an  anemia  or  an  hysteric  convulsion,  or  one  due  to 
nervous  irritability.  A  true  epileptic  convulsion  may  occur, 
but  this  is  not  accompanied  by  albuminuria,  has  not  the  same 
prodromata  nor  the  rise  of  temperature,  and  there  is,  as  a 
rule,  a  definite  history  of  previous  attacks.  Meningitis  is 
accompanied  by  vomiting,  optic  neuritis,  opisthotonos,  and  a 
rise  of  temperature  before  the  onset  of  the  convulsion. 

When  is  curettage  of  the  uterus  justifiable  in  obstetric 
practice,  and  how  should  it  be  performed? 

Curettage  is  required  whenever  there  has  occurred  a  reten- 
tion of  some  of  the  products  of  conception  either  after  abor- 
tion or  labor.  The  best  curet  is  the  finger  of  the  obstetrician, 
but  if  this  will  not  answer,  the  dull  curet  may  be  employed 
or  the  placental  forceps,  under  thorough  asepsis  and  anti- 
sepsis. In  curetting  the  uterine  cavity  the  walls  should  be 
scraped  systematically  and  without  great  pressure.  The  dan- 
gers are  hemorrhage  and  perforation. 

Define  puerperal  mania.  Give  its  etiology,  symptoms 
and  treatment. 

Puerperal  mania  is  the  most  common  form  of  puerperal 


OBSTETRICS  AND  GYNECOLOGY.  715 

insanity,  or  insanity  occurring  during  the  lying-in  period. 
It  may  result  from  heredity,  primiparity,  anxiety,  dystocia, 
and  septic  infection.  Some  authorities  attribute  all  the  cases 
to  septic  infection.  The  disease  appears  with  alarming  ab- 
ruptness. Without  warning  the  patient  becomes  maniacal  or 
wildly  delirious,  and  suft'ers  from  the  most  peculiar  hallu- 
cinations. A  homicidal  or  suicidal  tendency  is  common.  25 
to  35  per  cent,  of  the  cases  die  from  exhaustion  or  from  sep- 
ticemia, or  remain  permanently  insane.  The  patient  should 
be  confined  in  a  hospital  and  given  nerve-sedatives,  bromides, 
hyoscine,  trional,  sulfonal  and  tonics.  Rest  and  mental  diver- 
sion are  essential. 

What  hygienic  precautions  are  necessary  for  a  nursing 
child  if  the  mother  has  sore  nipples? 

If  the  nipples  are  fissured  the  child  may  svick  in  blood  and 
suffer  from  hematemesis.  It  should  temporarily  be  fed  on  the 
bottle  or  from  a  spoon,  but  returned  to  the  breast  as  soon  as 
the  nipple  will  permit.     An  artificial  nipple  may  also  be  used. 

Give  the  management  in  a  case  of  (a)  flat  or  inverted 
nipples,  and  (b)  cracked  nipples. 

A  flat  or  inverted  nipple  requires  gentle  traction  and  manip- 
ulation during  the  last  weeks  of  pregnancy,  or  more  powerful 
suction  through  a  breast-pump.  If  this  does  not  succeed  an 
artificial  nipple  must  be  employed.  Fissured  nipples  should 
be  kept  clean  and  dry,  and  anointed  between  the  nursing  with 
sweet  oil.  In  worse  cases  healing  applications  are  necessary, 
as  ichthyol  in  lanolin  or  glycerin,  or  1  dram  each  of  bismuth 
subnitrate  and  castor  oil,  compound  tincture  of  benzoin,  or  a 
4  to  8  per  cont.  solution  of  silver  nitrate  after  cocainization. 
The  child  should  not  nurse  from  these  nipples. 

Give  the  varieties,  pathology,  symptoms  and  treatment 
of  puerperal  mastitis. 

Mastitis,  or  inflammation  of  the  mammary  gland,  may  be 
suppurative  or  non-suppurative.  It  is  almost  always  due  to 
septic  infection  occurring  through  a  fissured  nipple.     Occa- 


716  OBSTETRICS  AND  GYNECOLOGY. 

sionally  it  may  result  from  caking  of  the  breasts  or  milk-stasis. 
The  pathology  consists  essentially  in  an  acute  inflammation 
of  the  cellular  tissue  of  the  gland.  The  symptoms  are  acute 
pain,  inflammation,  reddening  of  the  surface,  induration,  mal- 
aise, elevation  of  temperature,  and  headache.  The  treatment 
consists  in  hot  compresses  of  lead-water  and  laudanum,  the 
ice-bag,  the  application  of  a  mammary  binder,  and  ichthyol 
or  belladonna  locally ;  the  child  should  not  nurse.  The  bowels 
should  be  opened. 

Give  the  symptoms  and  treatment  of  mammary  abscess. 

If  mastitis  advances  to  suppuration  the  symptoms  will 
change.  This  is  most  common  in  the  third  or  fourth  week  of 
the  puerperium.  The  pain  becomes  dull  and  throbbing ;  rigor 
or  chills  are  noted;  the  fever  becomes  hectic  in  type;  the 
indurated  portion  of  the  breast  becomes  softer  at  a  certain 
point,  and  fluctuation  may  be  noted ;  the  surface  of  the  gland 
becomes  edematous,  livid  and  glazed.  When  the  abscess  is 
situated  deeply  in  the  areolar  tissue  just  above  the  pectoral 
muscles  a  postmammary  or  siibmanimary  abscess  results.  In 
this  case  the  pus  is  very  apt  to  burrow,  and  the  gland  is  raised 
from  the  chest  and  becomes  protuberant.  The  treatment  of 
abscess  is  early  incision,  the  line  of  incision  radiating  from 
the  nipple ;  the  wound  should  be  bathed  in  mercuric  chloride 
(1:4000)  and  packed  with  sterile  gauze. 

What  is  the  treatment  of  galactorrhea? 

Gralactorrhea  is  an  excessive  flow  of  milk  from  the  engorged 
breasts.  It  may  be  corrected  by  feeding  the  infant  at  regular 
intervals,  and  between  the  feedings  the  breast-pump  may  be 
employed  to  remove  the  excessive  flow.  Ergot  may  be  admin- 
istered in  small  amounts,  potassium  iodide  given  in  doses  of 
10  grains  three  times  daily,  and  belladonna  ointment  applied 
locally,  or  a  5  per  cent,  solution  of  cocaine  in  equal  parts  of 
glycerin  and  water. 

To  what  dangers  in  pregnancy  and  labor  does  gonorrhea 
of  the  mother  expose  her  and  her  offspring? 

During  pregnancy  a  gonorrheal  woman  may  develop  a  pus- 


OBSTETBICS  AND  GYNECOLOGY.  717 

tube,  which  may  rupture  or  cause  an  abortion  and  expose  her 
to  the  development  of  septic  infection.  A  gonorrheal  woman 
is  always  in  imminent  danger  of  puerperal  sepsis  after  the 
delivery  of  her  child.  The  child  is  exposed  to  the  danger  of 
ophthalmia  neonatorum. 

Give  the  symptoms,  treatment  and  prognosis  of  oph= 
thalmia  neonatorum.  State  its  causes  and  the  means  of 
prevention. 

Ophthalmia  neonatorum  is  a  purulent  inflammation  of  the 
conjunctiva  of  the  infant  due  to  infection  at  birth  by  gonor- 
I'heal  virus  contained  in  the  uterine  and  vaginal  discharges. 
It  is  very  virulent,  and  frequently  results  in  total  loss  of 
sight  from  perforation  of  the  cornea  and  destruction  of  the 
superficial  tissues.  The  symptoms  are  reddening  and  edema 
of  the  palpebrge,  agglutination  of  the  lids,  profuse  purulent 
discharge,  a  bright-red  appearance  of  the  conjunctivae,  and 
later  ulceration  and  perforation  of  the  cornea.  The  prognosis 
is  good  unless  corneal  ulceration  occurs.  The  treatment  is 
mainly  prophylactic,  and  this  consists  in  frequent  vaginal 
douching  during  labor,  and,  immediately  after  the  birth  of 
the  head,  cleansing  of  the  eyes  with  warm  sterilized  water, 
followed  by  the  instillation  of  a  few  drops  of  a  2  per  cent, 
solution  of  silver  nitrate.  After  the  disease  has  appeared  the 
cleaning  must  be  done  hourly  (Crede's  method)  with  warm 
water,  followed  in  alternate  hours  by  mercuric  chloride  1  to 
5000  to  8000,  and  a  saturated  solution  of  boric  acid.  Twice 
daily  an  application  of  silver  nitrate  4  per  cent,  solution  may 
be  used.  The  well  eye  should  be  protected  with  a  collodion 
dressing. 

Give  the  pathology  of  hydrocephalus.  State  how  hy- 
drocephalus may  be  recognized  before  delivery,  and  how 
such  a  complication  should  be  dealt  with. 

II}f<h'o<( phaJus  is  a  collection  of  serous  fluid  at  .some  point 
within  the  cerebral  substance  (internal  hydrocephalus)  or 
outside    the    brain-substance    (external   hydrocephalus) ,    pre- 


718  OBSTETRICS  AND  GYNECOLOGY. 

venting  closure  of  the  fontanels  and  causing  enlargement  of 
the  skull.  It  is  probably  a  sequel  of  some  obscure  form  of 
inflammation  of  the  cerebral  meninges.  The  vaginal  finger 
detects  bulging  fontanels  and  widely  separated  sutures,  both 
yielding  the  sensation  of  fluctuation.  Occasionally  crepita- 
tion may  be  noted.  Abdominal  palpation  reveals  an  unusual 
size  of  the  head.  The  treatment  consists  in  aseptic  puncture 
through  a  fontanel  or  suture;  if  this  fails  craniotomy  is  in- 
dicated. 

How  may  multiple  (twin)  pregnancy  be  recognized? 
State  how  it  may  complicate  labor,  and  show  how  labor 
should  be  managed  when  this  condition  exists. 

A  twin  pregnancy  may  be  recognized  by  the  unusual  size 
of  the  abdomen,  by  the  presence  of  two  distinct  fetal  heart- 
beats, heard  best  at  different  points  of  the  abdominal  sur- 
face ;  there  may  be  two  distinct  placental  souffles,  irregularity 
in  the  outline  of  the  uterus,  the  presence  of  a  number  of  fetal 
extremities  or  parts,  and  the  ability  to  outline  two  fetuses. 
The  dangers  are  uterine  inertia,  abnormal  presentations,  im- 
perfect development  of  the  fetuses,  the  formation  of  mon- 
strosities, and  locking  of  the  babies.  The  first  child  present- 
ing normally,  labor  should  proceed  normally;  after  its  birth 
the  second  child  should  be  made  to  present  in  a  proper  man- 
ner, and  then  I  dram  of  the  fluid  extract  of  ergot  should 
be  administered.  Not  infrequently  a  forceps-delivery  is  re- 
quired. 

What  complications  may  arise  in  a  twin  labor,  and  how 
may  they  be  overcome? 

Malpresentation  and  malposition  are  frequent  and  must  be 
corrected.  Locking  of  the  heads  requires  separation  of  the 
chins,  the  application  of  forceps  or  decapitation. 

What  is  superfetation,  and  how  does  it  take  place? 

Superfetation  is  the  supposed  fertilization  of  an  ovum  when 
there  is  another  from  a  previous  ovulation  in  uterogestation. 
There  is  considerable  doubt  as  to  the  possibility  of  such  an 


OBSTETRICS  AND  GYNECOLOGY.  719 

occurrence.  If  it  does  occur  it  wall  probably  take  place 
within  the  first  few  days  after  the  primary  conception,  i.  e., 
before  the  formation  of  the  decidua.  The  occurrence  of 
superfetation  at  a  more  advanced  stage  in  the  development  of 
the  primarily  fertilized  ovum  seems,  however,  to  have  been 
proved  by  remarkable  cases  reported  by  eminent  men. 

What  is  meant  by  prolapse  of  the  funis?  When  does  it 
occur?  What  are  its  dangers?  How  would  you  manage 
such  a  case? 

Prolapse  of  the  cord  consists  in  the  descent  of  a  loop  of 
the  umbilical  cord  in  advance  of  the  presenting  fetal  portion. 
It  occurs  in  certain  malpositions  and  malpresentations  of  the 
fetus,  in  multiple  pregnancy,  in  hydramnios  with  sudden 
escape  of  the  liquor  amnii,  and  in  contracted  pelvis  when  the 
fetal  head  does  not  properly  fit  into  the  superior  strait.  The 
danger  is  fetal  death  from  asphyxiation  due  to  pressure  on 
the  cord.  The  treatment  consists  in  replacement  of  the  cord, 
the  woman  resting  in  the  knee-chest  or  Trendelenburg  pos- 
ture. This  may  be  accomplished  by  gravity,  aided  by  the 
hand  or  by  a  respositor.  If  this  fails,  podalic  vei-sion  may  be 
performed  or  the  child  hastily  delivered  by  forceps. 

What  is  premature  respiration? 

The  establishment  of  the  function  of  respiration  before  de- 
livery of  the  child  has  been  accomplished.  This  is  due  to  the 
entrance  of  air  into  the  birth-canal,  and  occurs  in  cases  of 
dystocia  or  during  the  performance  of  version.  The  danger 
is  insufflation  of  liquor  amnii  or  clots,  with  the  development 
of  fetal  pneumonia. 

How  does  constitutional  syphilis  in  the  parents  affect 
the  infant,  and  how  can  you  detect  its  presence  in  the 
infant? 

The  offspring  of  syphilitic  parents  is  generally  infected  by 
the  disease.  Congenital  syphilis  will  be  shown  by  the  follow- 
ing symptoms :  Undersize  of  the  fetus,  delivery  at  term  of  a 
still-born  baby,  syphilitic  pemphigus  on  the  palms  and  soles, 


720  OBSTETRICS  AND  GYNECOLOGY. 

enlargement  of  the  liver  and  glands  of  the  body,  catarrhal  or 
white  pneumonia,  and  a  line  of  fatty  tissue  between  the  epi- 
physis and  diaphysis  of  the  long  bones.  If  the  child  be  born 
alive  and  apparently  healthy  it  will  develop  a  coryza  or 
"snuffles"  at  the  expiration  of  four  or  five  weeks,  followed 
by  the  appearance  of  eruptions  over  the  body  and  the  devel- 
opment of  marasmus. 

Give  the  causes  and  treatment  of  umbilical  hemorrhage 
of  the  new=born  child. 

Primary  omphalorrhagia  results  from  loose  ligature  or 
laceration  of  the  cord,  and  occurs  immediately  after  birth. 
Secondary  hemorrhage  occurs  at  the  time  of  separation  of  the 
cord,  and  is  due  to  a  dislodgement  of  the  clots  or  to  the 
hemorrhagic  diathesis.  The  treatment  consists  in  religation  of 
the  cord,  the  application  of  a  firm  compress  with  an  astringent 
solution,  the  application  of  a  firm  plaster  of  Paris  dressing, 
or  of  a  figure-eight  ligature  applied  over  hare-lip  pins. 

How  would  you  decide  whether  a  dead  infant  had  been 
born  alive? 

By  the  presence  of  air  in  the  lungs  {hypostatic  test). 

What  are  the  causes  of  still=birth,  and  how  should  a 
still=born  child  be  treated? 

The  causes  of  still-birth  are  various  intra-uterine  diseases, 
asphyxia  from  pressure  on  the  cord  or  interference  with  the 
fetoplacental  circulation,  as  in  eclampsia  or  premature  sepa- 
ration of  the  placenta,  and  traumatism  during  some  obstetric 
operation.  Such  a  child  should  be  handled  tenderly  and  be 
given  a  decent  burial.  The  term  "still-birth"  should  not  be 
confounded  with  asphyxia  neonatorum. 

Give  the  etymology  and  uses  of  the  forceps,  and  name 
the  conditions  for  their  application,  together  with  the 
rules  therefor  and  precautions  to  be  observed  in  the  same. 

The  obstetric  forceps  (a  Latin  word)  is  an  instrument  with 
two  blades  and  handles  for  pulling,  grasping  or  compressing 


OBSTETRICS  AND  GYNECOLOGY.  721 

the  fetus.  Its  use  is  indicated  by  the  presence  of  uterine 
inertia,  minor  degrees  of  pelvic  contraction,  threatened  fetal 
or  maternal  death,  and  to  correct  malpositions  of  the  fetal  head. 
In  order  that  the  instrument  may  be  applied  the  os  must  be 
dilated,  the  membranes  ruptured,  there  must  not  be  too  great 
disproportion  between  the  head  and  the  birth-canal,  the  part 
should  be  engaged,  and  the  labor  must  be  possible.  The  left 
blade  is  always  introduced  first,  and  must  be  grasped  in  the 
left  hand  and  carried  to  the  left  side  of  the  patient.  It  must 
not  be  forcibly  thrust  in,  but  must  be  slightly  rotated  in  order 
to  accommodate  it  to  the  pelvic  and  fetal  curves.  The  blade 
that  corresponds  in  name  to  the  pelvic  diameter  in  which  the 
fetal  presentation  is  lying  must  be  pried  forward  in  order  to 
grasp  the  fetal  head  on  the  sides. 

Describe  the  common  varieties  of  obstetric  forceps. 

A  short  forceps  is  one  in  which  the  blades  are  attached 
directly  to  the  handles  without  the  intervention  of  a  shank ; 
it  has  the  cephalic  curve  only,  and  is  used  only  when  the 
head  is  on  the  pelvic  floor  (loiu  forceps  operation).  The  loyig 
forceps  is  one  in  which  a  shank  is  placed  between  the  handles 
and  the  blades;  it  has  a  pelvic  curve,  as  well  as  the  cephalic. 
It  may  be  used  at  the  superior  strait,  but  is  usually  applied 
to  the  head  in  the  pelvic  cavity  {median  forceps  operation). 
The  axis  traction  forceps  is  a  long  forceps,  in  which,  by  an 
appliance  or  supplementary  handle  attached  to  the  under 
surface  of  the  blades,  the  traction  force  is  constantly  exerted 
in  the  line  of  the  axis  of  the  parturient  canal.  It  is  used  at 
the  superior  strait  (high  forceps  operation). 

Describe  the  position  of  patient  and  physician  for  the 
readiest  means  of  applying  the  forceps. 

The  patient  lies  upon  her  back  in  the  lithotomy  position, 
with  the  limbs  flexed  and  the  buttocks  over  the  side  of  the 
bed.     The  physician  sits  on  a  chair  between  the  thighs,  which 
are  separated  and  held  by  assistants. 
46 


722  OBSTETRICS  AND  GYNECOLOGY. 

In  what  direction  should  traction  be  made  when  the 
fetal  head  is  in  the  cavity  of  the  pelvis? 

At  first  downward  and  outward,  then  upward  and  back- 
ward. 

What  powers  may  be  exerted  by  the  forceps? 

The  forceps  are  generally  used  as  tractors.  They  may  be 
employed  as  levers,  rotators,  and  compressors. 

What  are  the  dangers  in  the  use  of  forceps,  and  how 
are  such  dangers  to  be  avoided? 

The  dangers  are  slipping  of  the  instrument,  septic  infec- 
tion, laceration  of  the  cervix  and  soft  tissues,  and  fatal  com- 
pression of  the  fetal  head.  If  applied  gently,  without  force, 
and  in  the  proper  (less)  diameters  of  the  fetal  skull,  and  if 
thorough  asepsis  be  employed,  these  dangers  may  be  obviated. 

Describe  the  technic  of  the  high  forceps  operation. 

The  instrument  (axis-traction  forceps)  must  be  introduced 
through  the  cervix,  and  applied  to  the  head  in  the  best  diam- 
eter possible.  The  grip  is  a  vicious  one,  because  a  large  diam- 
eter must  be  seized  and  there  is  danger  of  slipping.  Traction 
is  made  well  down  at  first,  and  as  the  head  descends  and  the 
upper  handles  of  the  instrument  rise  the  extra  handles  must 
be  raised  in  order  to  keep  the  two  handles  together.  When 
the  head  is  low  enough  the  instrument  should  be  withdrawn 
and  reapplied  in  a  better  position,  or  a  simple  instrument 
used. 

Describe  the  occasion  for  the  application  of  the  forceps 
in  the  inferior  strait. 

This  is  a  low  operation.  The  blades  are  introduced  in  the 
manner  already  described,  and  traction  made  outward  and 
downward  until  the  floor  is  reached.  The  head  is  then  pulled 
upward  and  outward  and  then  upward  and  backward  until 
it  emerges  through  the  vulvar  orifice.  The  instrument  in  the 
last  stage  of  delivery  is  grasped  in  the  right  hand  only,  as  a 
dagger  would  be  held,  and  the  left  hand  spans  the  perineum 
in  order  to  regulate  the  degree  of  distension. 


OBSTETRICS  AND  GYNECOLOGY.  723 

Describe  the  use  of  the  forceps  in  the  occipito=posterior 
position. 

This  is  a  double  forceps-operation.  The  occiput  generally 
lies  in  the  right  oblique  diameter  (R.  0.  P.)-  After  applying 
the  forceps  in  the  manner  already  described  traction  is  made 
downward  and  outward  until  the  head  impinges  upon  the 
pelvic  floor.  In  the  intervals  of  relaxation  a  certain  amount 
of  anterior  rotation  will  take  place.  This  will  carry  the  occi- 
put through  the  transverse  and  into  the  left  oblique  diameter. 
The  forceps  must  then  be  removed  and  reapplied  in  the  new 
diameter  to  prevent  inversion  of  the  instrument.  The  final 
traction  and  delivery  are  as  in  the  ordinary  anterior  forceps- 
delivery. 

What  indications  would  lead  you  to  insert  a  hand  into 
the  uterus,  and  what  precautions  should  you  observe? 

Failure  of  the  placenta  to  descend,  active  post-partum 
hemorrhage,  and  the  necessity  for  the  performance  of  version 
are  the  indications  for  the  introduction  of  the  hand  into  the 
uterus.  Thorough  asepsis  and  antisepsis  must  be  observed, 
and  the  hand  must  be  anointed  with  an  antiseptic  ointment. 

Define  version.  Give  the  varieties,  indications  and  dan- 
gers of  version,  together  with  the  preliminaries  and  the 
method  of  operating. 

Version  or  turning  is  an  obstetric  operation  whereby  by 
manual  efforts  the  position  of  the  fetus  in  utero  is  altered  so 
that  one  extremity  of  the  fetal  ellipse  is  made  to  take  the 
place  occupied  by  the  other  extremity  or  by  some  portion  of 
the  trunk.  The  varieties  of  version  are :  1.  Cephalic,  in  which 
the  head  is  made  to  present;  2.  Pelvic,  in  which  the  breech  is 
caused  to  present  at  the  superior  strait;  and  3.  Podalic,  in 
which  one  or  both  feet  are  grasped  and  drawn  down  into  the 
parturient  canal.  The  indications  for  version  are  malposition 
of  the  head  and  malprcsentations,  minor  degrees  of  pelvic 
contraction,  placenta  pra^via,  anything  indicating  speedy  de- 
li vorv  of  the  child,  as  threatened   fetal  or  maternal   death. 


724  OBSTETRICS  AND  GYNECOLOGY. 

The  dangers  of  the  operation  are  the  introduction  of  septic 
matter  or  of  air,  with  the  production  of  air-embolism,  rupture 
of  the  uterus,  laceration  of  the  cervix,  and  serious  fetal  in- 
jury. The  patient  should  be  anesthetized,  and  every  anti- 
septic precaution  observed.  The  membranes  should  not  be 
ruptured  until  the  hand  is  ready  to  be  introduced.  One  foot 
should  be  grasped  with  the  heel  in  the  palmar  surface  and  the 
child  gently  turned  to  avoid  undue  distension  of  the  lower 
uterine  segment.  After  the  body  is  turned  the  case  is  treated 
as  a  breech  presentation. 

Compare  version  with  the  employment  of  forceps,  and 
state  when  each  is  preferable. 

Version  is  a  shorter  operation,  and  one  that  is  to  be  pre- 
ferred when  haste  is  required.  The  dangers  of  sepsis  are 
greater  than  in  the  use  of  forceps,  and  also  the  danger  of 
uterine  rupture.  Version  should  be  used  when  the  forceps 
fail  to  engage  the  head  in  minor  degrees  of  pelvic  contraction. 
Version  cannot  be  employed  when  engagement  has  occurred 
or  when  there  is  a  high  position  of  Bandl's  ring. 

Describe  symphyseotomy,  and  give  the  indications  for 
its  performance. 

Symphyseotomy  or  division  of  the  pubic  symphysis  is  an 
extremely  limited  operation.  It  should  be  done,  if  done  at 
all,  only  in  those  cases  of  pelvic  contraction  in  which  the  con- 
jugate diameter  of  the  superior  strait  measures  from  7  to  8 
cm.  The  operation  of  choice  is  the  indirect  method,  in  which 
an  incision  II/2  to  2  inches  long  is  made  above  the  symphysis 
in  the  median  line,  and  after  separation  of  the  muscles  the 
Galbiati  knife  is  passed  down  beneath  the  symphysis  and  the 
bone  divided  from  below  upward  and  from  within  outward. 
As  the  symphysis  separates  gauze  is  packed  in  to  arrest  hem- 
orrhage. The  forceps  is  then  applied  and  the  child  extracted. 
After  delivery  the  wound  is  closed  and  the  bones  held  in  ap- 
position by  means  of  a  firm  pelvic  binder. 


OBSTETRICS  AND  GYNECOLOGY.  725 

Define  embryotomy  and  craniotomy,  and  give  the  indi= 
cations  for  and  method  of  operating  in  each. 

Eynhryotomy  is  any  mutilating  operation  upon  the  fetus. 
It  includes  decapitation  or  beheading  of  the  fetus,  amputa- 
tions of  the  fetal  extremities,  evisceration,  or  removal  of  the 
viscera  piecemeal,  and  craniotomy,  or  opening  of  the  fetal 
skull,  with  evacuation  of  the  brain.  The  technic  of  craniot- 
omy is  as  follows:  Vaginal  asepsis,  fixation  of  the  head  and 
scalp  with  volsella-forceps,  perforation  through  a  suture  or 
fontanel,  enlargement  of  the  perforation,  disorganization  of 
the  brain-mass,  decerebration  by  intra-cranial  injections  of 
warm  carbolized  water,  crushing  of  the  skull,  and  extraction 
of  the  head  by  the  craniotractor. 

Give  the  various  steps  in  embryotomy  in  the  transverse 
presentation. 

If  the  fetus  presents  by  the  back,  the  operation  of  spondy- 
lotomy or  division  of  the  vertebrae  is  indicated,  followed  by 
evisceration  or  by  delivery  of  the  fetal  body  doubled  upon 
itself.  Spondylotomy  or  rachiotomy  is  performed  by  means 
of  scissors,  as  is  also  evisceration.  Occasionally  in  impacted 
shoulder  presentations  the  operation  of  decapitation  will  be 
indicated.  This  can  be  accomplished  by  means  of  the  blunt 
or  the  sharp  hook  or  by  scissors.  The  body  is  readily  re- 
moved, and  the  head  must  then  be  grasped  by  forceps,  crushed 
and  extracted. 

Give  the  condition  requiring  Cesarean  section  or  hys- 
terectomy, and  describe  a  modified  form  of  the  operation. 

Cesarean  section  or  delivery  of  the  child  tiirough  an  ab- 
dominal and  uterine  incision  is  indicated  in  grave  degrees  of 
pelvic  contraction,  in  labor  obstructed  by  tumors  of  the  uterus 
and  pelvis,  in  irreducible  vaginal  tumors,  in  rupture  of  the 
uterus,  and  in  sudden  maternal  death.  The  original  Cesarean 
section,  in  which  an  incision  was  made  into  the  uterine  wall 
and  the  child  extracted,  has  been  modified  by  Sanger  as  fol- 
lows: The  abdomen  is  opened  in  the  median  line,  the  uterus 


726  OBSTETRICS  AND  GYNECOLOGY. 

delivered  and  towels  packed  around  it.  Then  while  the  uter- 
ine arteries  are  controlled  by  an  assistant  an  incision  is  made 
into  the  uterus  and  the  child  and  placenta  extracted.  The 
uterine  cavity  is  cleaned  out  and  sutures  introduced  to  close 
the  uterine  incision,  after  which  the  abdominal  wound  is 
closed. 

Define  Porro's  operation,  state  when  it  is  applicable,  and 
describe  the  methods  of  its  performance. 

The  Porro  operation  or  celiohysterectomy  consists  in  the 
extirpation  of  the  uterus  and  its  appendages  after  the  ex- 
traction of  the  fetus,  as  in  the  simple  Cesarean  section.  The 
indications  for  this  operation  are  extreme  degrees  of  pelvic 
contraction,  marked  atresia  of  the  cervix,  vagina  or  vulva,  the 
presence  of  large  bony  growths  in  the  pelvic  canal,  large 
fibrous  or  myomatous  tumors  of  the  uterus,  extensive  rupture 
of  the  uterus,  with  involvement  of  adjacent  structures,  a  re- 
laxed and  flabby  condition  of  the  uterus  after  the  section, 
and  a  septic  condition  of  the  uterus,  with  threatened  general 
septic  infection.  The  operation  is  the  same  up  to  extraction 
of  the  child.  The  ovarian  and  uterine  arteries  are  then  ligated 
and  the  uterus  amputated  at  the  cervical  junction.  The  case 
is  then  treated  as  an  ordinary  abdominal  section. 

What  complications  in  labor  justify  abdominal  section? 
Give  the  technic  of  the  operation. 

The  conditions  that  indicate  Cesarean  section,  rupture  of 
the  uterus,  retrodisplacement  of  the  uterus  with  incarceration, 
extra-uterine  pregnancy,  labor  complicated  with  tumors,  grave 
septic  infection  of  the  uterus,  appendages  or  broad  ligament, 
all  indicate  abdominal  section.  The  technic  is  that  of  Cesa- 
rean section  with  or  without  the  removal  of  the  uterus. 

Describe  the  malformations  of  the  uterus. 

Omng  to  failure  of  development  of  the  ducts  of  Miiller  we 
have  varying  degrees  of  double  uterus.  The  slightest  degrees 
are  known  as  uterus  incudiformis  and  uterus  cordiformis. 
From  these  minor  degrees  the  uterine  deformity  may  advance 


OBSTETRICS  AND  GYNECOLOGY.  727 

through  the  stages  of  uterus  septus,  subseptus,  partitus,  hi- 
partitus,  hilocularis  and  semipartitus.  In  the  uterus  bicornis 
the  two  tubes  unite  below,  but  are  separated  above.  The 
uterus  iLiiicornis  results  from  a  lack  of  development  of  one  of 
the  Miillerian  ducts,  its  fellow  undergoing  the  normal  process 
of  evolution. 

Describe  and  differentiate  anteversion,  retroversion  and 
prolapsus  of  the  uterus.  State  the  obstetric  significance 
of  each. 

Anteversion  of  the  uterus  is  a  bending  of  that  organ  for- 
ward ;  retroversion  is  a  bending  backward ;  prolapsus  is  a  fall- 
ing down  or  descent  of  the  organ.  Anteversion  may  prevent 
a  rising  of  the  uterus  if  the  organ  be  fixed,  and  so  interfere 
with  pregnancy.  Retroversion  of  a  pregnant  womb  may  re- 
sult in  incarceration  with  serious  results.  Prolapse  does  not 
as  a  rule  interfere  with  gestation;  the  uterus  returns  to  its 
normal  position  as  gestation  advances. 

Mention  the  symptoms  and  give  the  management  of 
long=retained   excretions   due   to   imperforate   hymen. 

In  addition  to  menstrual  suppression  there  will  be  noted 
cramp-like  pains  and  a  steadily  growing  cystic  tumor  in  the 
median  line  of  the  abdomen.  Palpation  will  elicit  pain. 
Vaginal  examination  will  show  the  imperforate  condition  of 
the  hymen.  The  treatment  consists  of  thorough  asepsis,  fol- 
lowed by  cervical  incision  into  the  hymen.  As  the  tarry  fluid 
escapes  a  two-way  catheter  should  be  introduced  and  an 
antiseptic  solution  allowed  to  flow  into  the  uterus  in  order  to 
prevent  shock  from  sudden  evacuation  and  to  prevent  septic 
infection. 

What  is  vaginismus?  How  may  it  be  recognized  and 
treated? 

Vaginismus  is  painful  spasm  of  the  vagina  and  vulva.  It 
results  from  rigid  hymen,  fissure,  and  other  local  conditions, 
and  appears  at  the  time  of  coitus  or  digital  exploration.  It 
is  best  treated  by  dilatation  under  anesthesia. 


728  OBSTETRICS  AND  GYNECOLOGY. 

What  method  should  be  employed  to  dilate  the  non= 
pregnant  uterus,  and  under  what  circumstances  is  the 
operation  justifiable? 

The  best  method  of  dilating  the  uterus  is  the  use  of  the 
dilator  of  Goodell  or  Wathens,  the  glove-stretching  apparatus. 
This  is  required  whenever  there  is  stenosis  of  the  cervical 
canal,  or  as  a  preliminary  step  to  the  operation  of  curettage. 

Is  ventrofixation  of  the  uterus  justifiable?  If  so,  state 
under  what  circumstances,  and  describe  the  operation. 

It  is  a  safe  and  proper  operation  for  the  correction  of 
retrodisplacement  of  the  uterus  in  women  past  the  child- 
bearing  period.  An  abdominal  opening  is  made,  the  uterus 
is  brought  forward,  and  a  stitch  is  passed  through  the  peri- 
toneal and  subperitoneal  tissues  on  one  side  of  the  incision, 
then  through  the  fundus  of  the  uterus  on  a  line  with  the 
Fallopian  tubes  and  through  the  corresponding  tissues  on  the 
other  side.  A  second  suture  must  be  passed  a  little  back  of 
this  and  firmly  secured.    The  abdominal  wound  is  then  closed. 

Under  what  conditions  may  shortening  of  the  round 
ligament  become  justifiable,  and  how  should  the  operation 
be  performed? 

Shortening  of  the  round  ligament  may  be  performed  when 
there  is  a  retrodisplacement  of  the  uterus.  It  is  best  per- 
formed by  Wylie's  method  or  some  other  of  the  intraperi- 
toneal methods,  the  ligaments  being  folded  upon  themselves 
or  implanted  further  back  upon  the  uterus.  Alexander's 
operation  is  shortening  of  these  ligaments  in  the  inguinal 
canals. 

Define  salpingitis,  state  its  causes  and  pathology,  and 
give  its  management. 

Salpingitis  is  inflammation  of  the  Fallopian  tubes.  It  may 
be  septic,  gonorrheal,  or  tuberculous  in  origin,  or  merely  a 
catarrhal  condition.  The  mucosa  swells,  secretes  a  fluid,  and 
if  the  edges  of  the  fimbriae  adhere  a  retension-cyst  is  formed. 
The  treatment  may  be  derivative,  and  consist  in  purgation,. 


OBSTETRICS  AND  GYNECOLOGY.  729 

with  local  applications  to  the  cervix  and  vaginal  vault,  or 
abdominal  section  may  be  performed  and  the  appendages  re- 
moved. 

Give  the  pathology  of  (a)  hydrosalpinx,  (b)  hematosal= 
pinx.     Give  the  diagnosis  and  treatment  of  each. 

Hydrosalpinx,  or  a  watery  collection  in  the  tube,  results 
from  an  old  pyosalpinx  or  purulent  collection.  The  pyogenic 
membrane  has  become  destroyed,  and  the  tluid  slowly  assumes 
the  watery  nature.  Hematosalpinx,  or  blood  in  the  tube,  re- 
sults almost  invariably  from  an  extra-uterine  pregnancy.  The 
treatment  of  each  is  excision.  The  diagnosis  is  made  by  the 
presence  of  a  sensitive  tumor  in  the  situation  of  the  tube,  with 
pain  on  the  affected  side. 

Define  endometritis,  and  give  its  causes,  varieties  and 
treatment. 

Endometritis,  or  inflammation  of  the  lining  membrane  of 
the  uterus,  may  be  septic,  gonorrheal,  traumatic,  catarrhal  or 
tuberculous  in  origin,  and  occur  as  a  glandular  or  as  an  inter- 
stitial affection,  or  as  both  combined.  It  may  be  treated  by 
local  applications,  depletion,  curettement,  intra-uterine  appli- 
cations, or  by  excision  of  the  uterus. 

Give  the  causes  of  pelvic  inflammation,  and  state  its 
relation  to  involvement  of  the  ovary. 

Pelvic  inflammation  is  generally  septic  or  gonorrheal  in 
origin.  It  may  result  from  exposure  to  cold  or  wet  or  from 
abrupt  stopping  of  the  menstrual  discharge.  If  active  and 
virulent  or  long  continued  there  follows  a  thickening  and 
chronic  inflammation  of  the  ovarian  capsule,  which  will  re- 
sult in  follicular  cysts  forming  in  the  ovarian  stroma  from 
inability  of  the  Graafian  follicles  to  rupture. 

Give  a  differential  diagnosis  between  ovaritis  and  ova- 
ralgia. 

Ovaritis,  or  inflammation  of  the  ovary,  is  associated  with 
all  the  symptoms  of  pelvic  inflammation,  including  pain,  leu- 


730  OBSTETRICS  AND  GYNECOLOGY. 

korrhea,  hemorrhage,  menstrual  disturbance,  and  swelling  of 
the  ovary  or  tumor-formation.  There  will  also  be  general 
symptoms,  as  fever  and  prosti^ation.  Ovaralgia  is  neuralgia 
of  the  ovary,  and  may  exist  independently  of  any  appreciable 
local  lesion.  It  is  more  apt  to  occur  at  or  near  the  menstrual 
period. 

Give  the  pathology  and  treatment  of  an  ovarian  cyst. 

An  ovarian  cyst  may  be  follicular,  as  already  described.  It 
may  be  a  multilocular  cyst  arising  from  rudimentary  Graafian 
follicles,  and  consisting  of  two  or  more  loculi  or  compart- 
ments; it  may  be  a  unilocular  cyst  springing  from  the  paro- 
varium, or  it  may  be  a  papillary  growth  arising  in  the  vertical 
tubules  of  the  paroophoron.  Whatever  its  origin  and  path- 
ology, it  should  be  removed  by  abdominal  section. 

Give  a  description  of  cystocele  and  rectocele.  State 
how  each  may  complicate  labor,  and  what  should  be  done 
in  the  arising  contingency. 

Cystocele  is  a  prolapse  of  the  anterior  vaginal  wall  and 
posterior  bladder  wall ;  rectocele  is  a  prolapse  of  the  pos- 
terior vaginal  wall  and  anterior  rectal  wall.  Both  cystocele 
and  rectocele  encroach  upon  the  calibre  of  the  vagina,  and 
may  be  caught  by  the  advancing  fetal  head  either  arresting 
its  progress  or  being  pushed  before  the  head;  in  the  latter 
case  the  submucous  tissue  is  torn  and  the  vaginal  prolapse 
made  worse.  The  treatment  consists  in  applying  forceps  to 
the  head  and  drawing  it  over  the  relaxed  vaginal  walls. 

How  would  you  diagnose  cystic  degeneration  of  the 
ovaries  from  other  forms  of  disease  which  simulate  it? 

Ovarian  cyst  may  be  distinguished  by  the  centrally 
situated  tumor,  the  area  of  central  dulness  ^^^th  coronal 
resonance,  the  immovability  of  the  tumor,  and  the  protub- 
erant abdomen  when  the  woman  assumes  the  dorsal  position. 
In  ascites  the  abdomen  flattens  and  the  flanks  bulge  when  the 
woman  lies  upon  her  back;  a  change  of  position  causes  a 
corresponding  change  in  the  area  of  dulness;  fluctuation  is 


OBSTETRICS  AND  GYNECOLOGY.  731 

marked;  there  is  an  area  of  central  resonance  with  coronal 
dulness,  and  an  associated  grave  organic  disease  may  be  de- 
tected. In  phantom  tumor  the  percussion-note  is  hyper- 
resonant,  and  examination  under  an  anesthetic  reveals  the 
true  condition. 

Give  the  early  diagnosis  and  the  treatment  of  cancer  of 
the  uterus. 

A  recurrence  of  bleeding  after  the  menopause;  an  angry 
appearance  of  the  cervix,  which  bleeds  on  the  slightest  touch ; 
a  peculiar  hardness  of  the  mucous  membrane  due  to  cellular 
infiltration;  an  acid  and  irritating  discharge,  which  may  or 
may  not  be  fetid,  and  dull  sacral  pains  would  lead  to  the 
suspicion  of  cancer.  A  microscopic  examination  would  then 
complete  the  diagnosis.  The  only  treatment  consists  in  total 
extirpation  of  the  uterus. 

Give  the  diagnosis  and  treatment  of  anemia  and  chIo= 
rosis. 

Chlorosis  is  the  "green  sickness"  of  young  girls.  These 
girls  are  generally  stout  and  well  nourished,  but  present  a 
peculiar  green  color;  they  suffer  from  nosebleed  not  infre- 
quently and  attacks  of  vertigo  and  syncope.  In  true  anemia 
there  is  an  extreme  pallor,  with  marked  diminution  in  the  red 
blood-corpuscles  and  hemoglobin  and  more  or  less  wasting. 
Anemia  is  generally  associated  with  some  grave  organic  dis- 
ease. The  treatment  of  both  conditions  consists  in  good  food, 
change  of  scene,  rest  and  tonics,  including  iron,  strychnine 
and  arsenic. 

What  are  the  symptoms  and  treatment  of  amenorrhea? 

Amenorrhea  is  a  total  suppression  of  the  menstrual  flow. 
It  is  generally  associated  with  anemic  conditions,  and  may 
be  accompanied  by  leukorrhea  and  vague  pelvic  pains.  The 
treatment  consists  in  tonics,  good  food,  and  the  use  of  iron, 
oxalic  acid,  potassium  permanganate,  manganese,  and  the 
other  so-called  emmenagogues. 


732  OBSTETRICS  AND  GYNECOLOGY. 

What  is  the  menopause,  and  in  what  manner  would  you 
explain  the  theory  that  it  is  a  critical  period  in  a  woman's 
life? 

The  menopause  is  the  cessation  of  the  phenomenon  of  men- 
struation, occurring  usually  at  the  age  of  43  to  45.  At  this 
time  the  ovarian  influence  ceases,  and  because  of  the  tendency 
to  the  development  of  obesity  and  of  uterine  cancer  at  or 
after  this  period  it  has  long  been  regarded  as  a  critical  period 
in  the  life  of  the  woman.  Various  forms  of  insanity  may 
also  develop  at  this  time.  The  post-climacteric  diseases  may 
assume  a  very  serious  aspect. 

Enumerate  the  perils  of  premature  parturition. 

Premature  labor  subjects  the  woman  to  the  dangers  of 
hemorrhage  from  partial  detachment  of  the  placenta,  cervical 
laceration  because  of  rigidity  of  the  parts,  and  sepsis  from 
retention  of  placental  debris. 

What  are  the  conditions  liable  to  produce  sepsis  after 
abortion? 

Imperfect  expulsion  of  the  product  of  conception  and  the 
necessity  in  many  cases  of  digital  assistance. 

Before  the  head  engages,  how  would  you  convert  an 
L.  O.  P.  into  an  L.  O.  A.  position? 

If  possible  by  the  position  of  the  mother,  who  should  lie 
upon  the  left  side.  If  this  fails,  the  head  may  be  rotated 
forward  by  the  hand  or  by  forceps  applied  to  the  sides  and 
gently  turned,  not,  however,  reversing  their  normal  position 
in  the  pelvis.  One  blade  of  the  forceps,  the  vectis,  may  be 
employed  for  the  purpose  in  suitable  cases. 

What  injuries  may  happen  to  the  vagina  and  rectum 
during  labor,  and  how  may  they  be  avoided? 

The  vaginal  walls  may  be  pushed  or  drawn  ahead  of  the 
advancing  part  and  partially  detached  from  their  support; 
they  may  be  cut  or  torn  by  the  blades  of  the  forceps,  which 
may  also  cut  through  the  rectovaginal  septum  and  produce  a. 


OB  ST  ETHICS  AND  GYNECOLOGY.  733 

complete  perineal  laceration.  These  accidents  may  be  pre- 
vented largely  by  preservation  of  the  bag  of  waters  as  long 
as  possible,  by  thorough  lubrication  of  the  parts,  and  by  the 
proper  use  of  the  forceps  when  these  become  necessary. 

Describe  the  method  of  applying  forceps  in  R.  O.  A. 
presentation. 

The  head  lies  in  the  left  oblique  pelvic  diameter ;  therefore 
the  left  blade  first  introduced  is  pried  forward  until  the  blade 
rests  over  the  upper  fetal  ear,  the  handle  of  the  instrument 
looking  downward  and  outward  to  the  operator's  left.  The 
right  blade  is  then  introduced  and  depressed  without  rota- 
tion until  it  fits  into  the  slot  of  the  other  blade. 

Describe  the  operation  in  detail  for  the  immediate  re= 
pair  of  complete  laceration  of  the  perineum. 

After  cleansing  the  parts,  the  patient  being  under  an  anes- 
thetic, a  stitch  is  passed  well  behind  the  anal  orifice  and 
toward  the  median  line  with  an  outward  sweep,  so  as  to 
embrace  the  retracted  sphincter  fibers;  it  is  then  carried  up 
to  the  apex  of  the  tear  and  caused  to  traverse  a  smilar  course 
upon  the  other  side  of  the  fissure,  emerging  at  the  point  of 
introduction.  A  second  stitch  is  then  introduced  at  the  point 
of  retraction  of  the  outermost  sphincter-fibers  and  carried  in 
and  toward  the  apex  of  the  tear,  traversing  a  similar  course 
on  the  other  side  to  emerge  at  the  outermost  retracted 
sphincter-fibers  of  that  side.  These  two  stitches  close  the 
sphincter.  The  perineum  above  is  then  closed  by  transverse 
sutures  introduced  in  the  usual  manner.  If  the  rectal  septum 
is  torn,  it  must  first  be  closed  by  a  running  catgut  suture. 

Give  the  mechanism  of  delivery  of  a  R.  O.  P.  presen- 
tation. 

After  great  labor-pains  the  head  descends  until  the  occiput 
strikes  the  pelvic  floor  high  up  posteriorly;  it  is  then  rotated 
anteriorly  through  %  of  a  half  circle  until  it  rests  under  the 
pubic  symphysis.  While  doing  this  the  shoulders  rotate  high 
up  in  the  false  pelvis  from  right  to  left  until  they  rest  in  the 


734  OBSTETRICS  AND  GYNECOLOGY. 

right  oblique  diameter,  having  primarily  rested  on  the  line 
of  the  left  oblique  diameter.  The  head  is  then  delivered  by- 
extension,  rotation  occurs  toward  the  right,  the  anterior 
shoulder  advances  from  the  left  side  to  the  median  line,  and 
the  shoulders  and  body  are  then  delivered. 

What  abnormal  conditions  in  pregnant  women  are  pre= 
judicial  to  the  life  of  mother  or  child? 

Syphilis,  tuberculosis,  anemia,  vomiting,  zymotic  diseases, 
placenta  praevia,  pelvic  deformities,  renal  disease,  tumors,  and 
degenerations  of  the  membranes. 

Describe  the  method  of  delivery  in  a  leg=presentation. 

This  is  a  modified  breech-presentation.  The  leg  should  be 
drawn  down  and  the  other  made  to  engage.  The  labor  may 
proceed  as  a  breech  delivery,  or  the  child  may  be  rapidly  ex- 
tracted as  after  version. 

State  the  conditions  compelling  artificial  feeding,  and 
describe  the  proper  method  of  modifying  cow's  milk  for 
the  newly  born. 

Lack  of  milk- formation ;  refusal  of  the  child  to  nurse; 
tuberculosis  or  other  grave  maternal  disease;  high  fever. 
Normal  cow's  milk  should  be  diluted  by  10  or  12  parts  of 
water,  some  sugar  of  milk  added,  lime-water  1  or  2  drams  to 
the  mixture,  and  the  whole  subjected  to  Pasteurization  before 
being  administered  in  sterile  bottles. 

Give  the  relations  of  the  cephalic  and  pelvic  diameter 
at  3  points  during  the  birth  of  a  L.  O.  A.    presentation. 

At  the  beginning  of  the  labor  the  suboccipito-bregmatic  and 
bitemporal  diameters  of  the  head  are  concerned,  the  sagittal 
suture  running  in  the  right  oblique  pelvic  diameter.  After 
engagement  perfect  flexion  causes  the  trachelobregmatic  and 
biparietal  diameters  to  engage.  After  anterior  rotation  the 
head  rests  in  the  conjugate  pelvic  diameter  and  the  head  is 
delivered  by  extending  under  the  subpubic  ligament. 


OBSTETRICS  AND  GYNECOLOGY.  735 

Diagnose  pregnancy  in  the  sixth  month  from  phantom 
tumor. 

In  phantom  tumor  there  is  general  tympany  over  the  dis- 
tended abdomen,  there  are  no  hard  parts  to  be  felt,  and  under 
ether  the  entire  condition  clears  up.  The  pregnancy  at  six 
months  wall  give  all  the  absolute  signs  of  pregnancy,  includ- 
ing movements,  heart-beats,  and  ability  to  outline  the  fetal 
parts. 

Differentiate  an  ovarian  cyst,  a  uterine  fibroid,  and 
pregnancy  at  the  fifth  month. 

At  the  fifth  month  of  pregnancy  there  will  be  found  a 
pyramidal  tumor  almost  reaching  to  the  umbilicus,  cystic  upon 
one  side  and  firm  upon  the  other,  alternately  hardening  and 
contracting.  The  fetal  outlines  may  be  determined  indis- 
tinctly, ballottement  is  present,  and  the  soft  signs  of  preg- 
nancy may  be  found. 

An  ovarian  cyst  is  of  slower  growth,  is  entirely  cystic  to 
the  feel,  fluctuation  will  be  present,  the  tumor  will  be  more 
or  less  to  one  side  of  the  median  line;  none  of  the  signs  of 
pregnancy  will  exist;  menstruation  may  persist. 

A  uterine  fibroid  will  be  much  harder,  irregular  in  outline, 
without  the  signs  of  pregnancy.  ^Menstruation  will  be  fre- 
quent and  irregular,  and  increased  in  amount. 

Give  the  management  of  a  pregnancy  and  labor  compli- 
cated by  a  fibroid  tumor  of  the  uterus. 

If  the  tumor  is  lai'ge  and  the  pregnancy  early,  abortion 
may  be  induced.  In  later  pregnancies,  the  tumor  being  situ- 
Mted  on  the  anterior  uterine  wall,  the  patient  may  be  allowed 
to  go  to  term  and  may  spontaneously  deliver  herself.  If  not. 
Cesarean  section  is  indicated.  If  the  tumor  is  lodged  in  the 
pelvis  or  is  in  the  posterior  uterine  wall,  elective  Cesarean 
section  with  the  Porro  operation  may  be  performed. 

Define  multiple  pregnancy. 

Pregnancy  in  which  nioi'c  than  one  fetus  is  present  in  the 
uterine  cavitv  oi-  in  tlu'  maternal  abdomen. 


736  OBSTETRICS  AND  GYNECOLOGY. 

Give  the  management  of  delay  in  the  second  stage  of 
Jabor. 

If  due  to  inertia,  rest,  firm  abdominal  binder,  quinine, 
friction  over  the  uterine  fundus.  If  due  to  obstruction,  as 
from  rigid  perineum,  rigid  cervix,  tumor,  or  pelvic  contrac- 
tion, correct  the  existing  cause  and  deliver  with  forceps  or  by 
some  other  operative  procedure. 

To  what  diseases  is  the  puerperal  breast  liable? 

Fissure  of  the  nipple,  mastitis,  abscess,  septic  infection. 
<;aking  of  the  milk. 

Describe  the  vulva.  Differentiate  the  vulva  of  a  parous 
woman  and  the  vulva  of  a  non=parous  woman. 

The  vulva  consists  of  the  mons  veneris  and  the  two  rolls  of 
fatty  tissue  known  as  the  labia  majora.  These  parts  are  cov- 
■ered  with  hair.  In  a  non-parous  woman  the  labia  are  in  close 
contact,  even  when  the  thighs  are  separated ;  in  a  woman 
who  has  given  birth  to  children  the  labia  are  either  lightly 
in  contact  or  the  orifice  is  patulous  and  relaxed. 

Describe  pelvimetry  and  state  its  obstetric  uses  and 
value. 

By  pelvimetry  is  meant  the  measurement  of  the  dimensions 
and  capacity  of  the  pelvis.  It  is  employed  to  determine  the 
■degree  of  pelvic  contraction  that  may  be  present,  and  the  re- 
lationship existing  between  the  respective  sizes  of  fetus  and 
pelvis.  By  its  use  grave  major  obstetric  operations  may  be 
avoided  by  the  premature  induction  of  labor,  or  the  operation 
of  choice  may  be  selected  and  both  fetal  and  maternal  life 
saved. 

Describe  the  genupectoral  posture  and  mention  some  of 
its  important  uses. 

The  genupectoral  or  knee-chest  posture  is  that  in  which 
the  patient,  resting  upon  her  knees  with  the  thighs  vertical, 
inclines  her  body  forward  until  she  rests  upon  the  upper 
portion  of  the  chest  with  the  head  turned  to  the  side  and  the 


OBSTETRICS  AND  GYNECOLOGY.  737 

arms  resting  above  the  head.  This  position  favors  gravita- 
tion of  the  viscera  out  of  the  pelvis,  permits  a  replacement 
of  a  retro-displaced  uterus,  the  return  of  a  hernia  through 
the  ring,  and  the  replacement  of  a  prolapsed  funis. 

Describe  the  causes  and  management  of  a  "  head=last  " 
labor. 

This  is  a  breech-labor,  and  results  from  a  reversal  of  the 
shape  of  the  fetal  ellipse,  the  cephalic  extremity  of  the  child 
becoming  the  larger;  it  may  also  depend  upon  a  deformed 
uterus  or  a  mild  degree  of  pelvic  contraction.  The  treatment 
consists  in  efforts  at  version  before  labor,  if  this  be  deemed 
best ;  inaction  during  the  first  and  second  stages  of  labor  until 
the  child  is  delivered  as  far  as  the  umbilicus,  and  then  a  rapid 
delivery  of  the  shoulders  and  head. 

Differentiate  prolapse  of  the  uterus  and  inversion  of  the 
uterus.     Give  the  management  of  each  condition. 

Prolapse  of  the  uterus  is  a  descent  or  falling  downward  of 
that  organ.  This  may  be  slight  in  degree  or  the  entire  uterus 
may  slide  bodily  through  the  vagina  and  appear  outside  the 
vulva,  the  vagina  being  inverted  in  its  descent.  Inversion  of 
the  uterus  is  a  turning  of  the  uterus  inside  out  like  a  finger  of 
a  glove.  A  rounded  tumor  results,  covered  with  the  uterine 
mucosa,  and  if  the  inversion  is  complete  the  orifice  of  the 
fallopian  tube  may  be  seen.  Prolapse  of  the  uterus  is  to 
be  treated  by  operative  procedures.  Either  the  organ  may 
be  amputated  or  else  it  may  be  replaced  and  held  in  position 
by  ventral  fixation  or  some  other  form  of  abdominal  operation, 
supplemented  by  restoration  of  the  pelvic  floor.  Acute  in- 
version of  the  uterus  must  be  immediately  reduced  and  a 
strip  of  gauze  introduced  into  the  cavity  of  the  uterus  to 
prevent  recui-renee.  In  chronic  inversion  a  hysterectomy 
should  be  performed. 

Describe  ventrosuspension  and  ventrifixation.  Under 
what  conditions  may  either  operation  be  justifiable? 

Wntrosuspcnsion  is  the  operation  of  suspending  the  uterus 
47 


738  OBSTETRICS  AND  GYNECOLOGY. 

from  the  peritoneal  lining  of  the  abdominal  cavity.  Ventrifixa- 
tion  is  the  method  in  which  the  sutures  are  passed  more  deeply 
into  the  fascia  and  muscle  of  the  abdominal  wall,  so  that 
the  uterus  is  not  suspended  but  is  fixed  to  the  wall. 
The  latter  operation  is  serviceable  only  after  the  child- 
bearing  period  is  ended,  and  is  used  to  correct  retrodisplace- 
ment  and  prolapsus  of  the  uterus.  The -suspension  is  used 
for  minor  degrees  of  backward  displacement  and  may  be  used 
in  younger  women. 

What  are  the  diagnostic  signs  of  chronic  inversion  of 
the  uterus.     Describe  an  operation  for  its  relief. 

There  is  present  a  hardened  inflamed  mass  projecting  from 
the  rim  of  the  cervix  into  the  vagina.  This  mass  cannot  be 
replaced  on  account  of  the  adhesions  that  have  formed.  It  is 
deep  red  in  color  and  may  be  the  seat  of  ulceration.  Palpa- 
tion above  reveals  a  cup-shaped  depression  instead  of  the 
normal  rotundity  of  the  uterine  fundus.  The  best  operative 
procedure  for  the  relief  of  this  condition  is  an  abdominal  hys- 
terectomy according  to  the  method  already  described. 

State  the  mechanical  and  the  surgical  treatment  appro= 
priate  to  retrodisplacements  of  the  uterus. 

The  use  of  pessaries  for  the  restoration  of  the  backward 
displaced  uterus  is  not  to  be  recommended  save  in  those 
cases  in  which  operative  interference  is  positively  refused. 
Then  the  Smith-Hodge  pessary  will  afford  relief  from  the 
symptoms  but  will  not  cure  the  condition.  The  operative 
methods  vary  according  to  the  condition,  age  of  the  patient, 
and  choice  of  the  operator.  An  Alexander  operation  may 
give  good  results,  or  some  modification  of  the  round  ligament 
operation,  as  Baldy's,  Ries'  or  Wylie's  may  be  tried.  Ventro- 
suspension  or  ventrifixation  should  be  performed  in  appro- 
priate cases. 

What  is  the  management  of  carcinoma  of  the  cervix 
with  reference  to  pregnancy  and  labor? 

The  increased  congestion  of  the  cervix  during  pregnancy 


OBSTETRICS  AND  GYNECOLOGY.  739 

favors  the  rapid  development  of  the  malignant  disease.  Ow- 
ing to  the  hardened  indurated  condition  of  the  cervix  dilata- 
tion at  the  time  of  labor  is  slow  or  even  impossible,  and  it 
may  become  necessary  to  perform  a  Cesarean  section  followed 
by  total  extirpation  of  the  uterus. 

Give  the  causes,  diagnosis  and  treatment  of  prolapse 
of  the  ovary. 

Ovarian  prolapse  is  produced  by  any  condition  increasing 
the  specific  gravity  of  the  organ  so  that  it  is  dragged  out  of 
its  seat  on  the  posterior  surface  of  the  broad  ligament.  Con- 
gestion of  the  organ,  fibroid  degeneration  or  tumor,  adhesions 
to  the  bowel  or  surrounding  tissues  may  all  result  in  dis- 
placement of  the  ovary.  Palpation  through  the  vagina  will 
then  reveal  the  ovary  lying  at  a  lower  level  than  normal,  as 
behind  the  cervix  near  the  level  of  the  internal  os.  There 
will  also  be  present  neuralgia  of  the  organ,  pelvic  weight  and 
burning,  and  pain  on  defecation  and  coitus.  The  treatment 
will  consist  either  in  suturing  of  the  elongated  ovarian  and 
tubo-ovarian  ligaments  to  the  upper  margin  of  the  broad  liga- 
ment or  to  the  pelvic  fascia,  or  in  total  extirpation  of  the 
prolapsed  organ. 

Describe  hysterectomy  for  uterine  fibromata. 

An  abdominal  incision  is  made;  all  adhesions  are  broken  up 
or,  if  dense,  ligated  and  cut;  the  ovarian  arteries  are  ligated 
in  the  upper  portion  of  the  broad  ligament  beyond  the  fim- 
briated extremities  of  the  tubes;  the  broad  ligaments  are 
then  divided  along  the  uterine  margin  as  far  down  as  the  in- 
ternal OS;  deep  ligatures  are  then  placed  to  include  the  uterine 
arteries,  care  being  taken  not  to  include  the  ureters  in  the 
grasp  of  the  needle;  the  bladder  and  peritoneum  are  stripped 
off  of  the  uterus,  and  the  cervix  divided  cautiously  from 
before  backward.  If  either  uterine  artery  squirts  it  must 
be  grasped  with  a  hemostate  and  another  ligature  passed 
deeply  around  it  through  the  broad  ligament.  The  anterior 
and  posterior  peritoneal  investments  are  then  united  by  a 


740  OBSTETRICS  AND  GYNECOLOGY. 

running  suture  of  fine  silk  or  catgut,  and  the  broad  liga- 
ment cavity  on  either  side  closed  in  the  same  way. 

Mention  the  causes  and  state  the  management  of  cystitis 
in  the  female. 

Cystitis  may  result  from  catheterization  with  an  unclean 
instrument;  it  may  result  from  gonorrheal  invasion  of  the 
bladder;  or  it  may  follow  exposure  to  cold  or  wet,  or  result 
from  the  presence  of  stones  or  foreign  bodies  in  the  bladder. 
Pressure  of  a  displaced  uterus  or  of  a  tumor  may  cause  the 
disease,  as  may  also  invasion  of  the  colon  bacillus  through 
peritoneal  adhesions,  or  the  wandering  into  the  bladder  of 
encysted  silk  ligatures.  The  treatment  consists  in  removal 
of  the  cause,  administration  of  boracic  acid  in  ten-grain  doses 
or  ammonium  benzoate  in  the  same  doses,  the  free  use  of 
water  or  flaxseed  tea  internally,  and  locally  the  washing-out  of 
the  bladder  with  sterile  water  and  if  necessary  the  crushing 
of  stones  or  preferably  their  removal  through  a  small  vaginal 
incision. 

Differentiate  vaginitis  and  vaginismus. 

Vaginismus  is  a  painful  spasm  of  the  vagina  and  vulva  due 
to  hymeneal  rigidity,  fissure  or  ulceration,  and  is  present  only 
during  coitus  or  digital  examination.  Vaginitis  is  inflam- 
mation of  the  lining  mucous  membrane  of  the  vagina,  due  to 
the  presence  of  the  gonococcus  or  more  rarely  to  irritation 
from  other  sources.  It  is  characterized  by  redness  and  swell- 
ing, burning  sensations  in  the  parts,  more  or  less  discharge, 
and  occasionally  by  the  presence  of  ulcerations.  The  treat- 
ment depends  upon  the  cause,  and  as  it  is  generally  gonorrheal 
in  origin  the  treatment  is  that  of  gonorrhea,  including  the 
use  of  the  silver  salts  and  injections  of  potassium  permangan- 
ate, bichloride  of  mercury  or  other  antiseptic  and  cleansing 
solutions. 

What  are  the  dangers  to  the  female  from  latent  gonor= 
rhea?     How  should  the  resultant  infection  be  treated? 

Fortunately   gonorrheal   infection   is   generally  limited    to 


OBSTETRICS  AND  GYNECOLOGY.  741 

the  vagina.  It  may  invade  the  uterine  cavity,  giving  rise  to 
an  incurable  form  of  endometritis,  or  it  may  rapidly  pass 
through  the  uterine  cavity,  and  entering  the  fallopian  tubes 
produce  a  tubal  abscess  with  accompanying  pelvic  inflamma- 
tion. The  gonorrheal  infection  of  the  uterine  cavity  may 
be  treated  by  active  cauterization  and  disinfection  of  the 
endometrium,  and  should  this  fail  hysterectomy  will  be  in- 
dicated. Tubal  abscess  requires  early  abdominal  incision  and 
extirpation  of  the  diseased  appendages. 

What  are  the  causes  and  the  results  of  atresia  of  the 
vagina?    How  should  the  resultant  conditions  be  managed? 

Atresia  of  the  vagina  follows  injuries,  abrasions  or  ulcer- 
ation of  the  mucous  lining.  There  may  result  merely  a 
lessening  of  the  caliber  of  the  organ,  or  the  vagina  be  totally 
obliterated  in  part  or  throughout  its  entire  length.  The  use 
of  dilators  has  not  been  generally  satisfactory,  although  it 
succeeds  on  certain  cases.  Skin-grafting,  or  the  adoption  of 
some  form  of  plastic  operation  may  be  necessary  to  correct 
the  resultant  deformity. 

Differentiate  between  menorrhagia  and  metrorrhagia. 
Give  the  management  of  each  condition. 

Menorrhagia  is  excessive  flow  of  blood  at  the  menstrual 
periods;  metrorrhagia  is  bleeding  between  the  periods. 
Menorrhagia  may  be  due  to  the  hemorrhagic  diathesis,  to  a 
condition  of  plethora,  to  uterine  displacement,  and  to  con- 
gestion and  inflammation  of  the  pelvic  viscera.  It  may  be 
treated  by  rest  in  bed  at  the  period,  the  correction  of  con- 
stipation, and  the  use  of  a  pessary  or  the  performance  of 
some  operation  to  correct  the  uterine  displacement.  Me- 
trorrhagia results  from  some  graver  uterine  or  pelvic  disease 
as  the  presence  of  fibroid  tumors,  cancer,  chronic  or  sub- 
acute salpingitis,  and  extrauterine  conditions.  It  is  treated 
by  remedies  or  operations  directed  toward  tlio  relief  of  the 
causative  condition. 


742  OBSTETRICS  AND  GYNECOLOGY. 

What  injuries  may  occur  to  the  birth=canal  during  Iabor» 
and  when  and  how  do  you  discover  and  treat  them? 

Rupture  of  the  uterus  may  occur  during  the  progress  of  an 
obstructed  labor.  It  occurs  late  in  the  second  stage  of  labor 
and  is  recognized  by  sudden  collapse  of  the  patient,  total  ar- 
rest of  the  labor  pains,  and  the  symptoms  of  internal  hemor- 
rhage. The  treatment  consists  in  an  immediate  abdominal 
section  with  extraction  of  the  fetus  and  its  appendages  fol- 
lowed by  suturing  of  the  uterine  rent  or  extirpation  of  the 
uterus.  Laceration  of  the  cervix  usually  occurs  during  the 
passage  of  the  child's  head.  It  may  result  from  the  use  of 
the  forceps.  It  is  to  be  repaired  after  the  puerperium. 
Laceration  of  the  vagina  and  perineum  occurs  at  the  close 
of  the  labor  either  from  the  spontaneous  expulsion  of  the 
head  or  from  the  use  of  forceps.  It  should  be  repaired  im- 
mediately after  the  labor  is  terminated. 

What  are  the  essential  causes  of  sterility  in  the  female? 
What  may  be  done  to  promote  fertility? 

Stenosis  of  the  cervical  canal,  acute  anteflexion  of  the 
uterus;  marked  rerto-displacement  of  the  uterus,  imperfect 
development  of  the  uterus,  absence  of  the  uterus  or  ovaries, 
profuse  and  acrid  leukorrhea — all  are  causes  of  sterility  on 
the  part  of  the  female.  Correction  of  the  stenosis  by  rapid 
progressive  dilatation  of  the  canal,  the  correction  of  the 
uterine  displacement  or  of  the  disease  causing  the  trouble, 
and  a  course  of  treatment  to  cure  the  leukorrhea  may  re- 
sult in  a  cure. 

Mention  the  principal  causes  of  dyspareunia  in  the 
female.     State  how  this  condition  may  be  relieved. 

Dyspareunia  or  painful  coitus  most  commonly  results 
from  rigidity  of  the  hymen.  It  may  result  from  fissuration 
or  ulceration  of  the  introitus  vaginae.  Rupture  of  the  hymen 
under  ether,  and  appropriate  treatment  applied  to  the  fissure 
or  ulcer  will  correct  the  condition. 


OBSTETRICS  AND  GYNECOLOGY.  743 

Describe  the  knee=-chest  posture  and  state  its  principal 
application  in  obstetries  and  in  gynecology. 

The  genupectoral  or  knee-chest  posture  is  that  in  which 
the  woman  rests  upon  her  knees  with  the  thighs  vertical,  while 
her  body  rests  upon  her  chest  with  the  head  turned  to  the 
side.  It  is  used  in  obstetrics  to  favor  the  return  of  a  pro- 
lapsed cord,  and  in  gynecology  to  aid  in  the  replacement  of  a 
recto-displaced  uterus. 

How  may  a  short  umbilical  cord  complicate  labor? 
State  the  management  of  such  a  condition. 

A  short  cord  may  retard  the  progress  of  labor  by  dragging 
back  the  child  between  the  pains,  or  it  may  cause  undue  trac- 
tion on  the  placenta  causing  premature  separation  of  that 
organ.  If  it  be  recognized  the  os  should  be  digitally  dilated 
and  the  child  extracted  quickly  by  forceps  or  version. 

Describe  toxemia  of  pregnancy,  mention  its  prodromal 
symptoms,  and  state  what  may  be  done  to  prevent  or  to 
relieve  this  condition? 

The  toxemia  of  pregnancy  is  the  poisoned  condition  of  the 
blood  in  pregnancy  in  which  there  is  a  retention  and  accu- 
mulation of  the  urates  in  the  blood  together  with  a  corres- 
ponding decrease  of  these  bodies  in  the  urine.  It  is  due  to  a 
deficient  excretory  action  of  the  kidneys,  but  this  may  also 
be  associated  with  some  imperfect  action  of  the  liver.  The 
prodromal  symptoms  of  this  condition  are  more  or  less  pro- 
gressive drowsiness,  headache  frontal  in  character,  pain  in  the 
epigastrium,  pallor  and  sometimes  swelling  of  the  face  especi- 
ally about  the  ears,  diminished  toxicity  of  the  urine,  fre- 
quently albuminuria.  Free  purgation,  the  administration 
of  diuretics  and  renal  stimulants,  the  use  of  a  milk  diet,  free 
bathing,  the  use  of  diaphoretics,  and,  if  necessary,  premature 
termination  of  the  pregnancy,  will  be  the  course  of  treatment 
to  be  pursued. 

What   principal    causes   operate    to    delay    labor    in    the 


744  OBHTETRWti  AND  GYNECOLOGY. 

first  stage?     What  should  be  done  to  overcome  the  diffi= 
culties  causing  the  delay? 

Uterine  inertia,  either  from  weakness  of  the  maternal 
muscles,  or  from  overdistension  by  hydramnios  or  multiple 
pregnancy;  also  malpositions  and  malpresentations  of  the 
fetal  parts.  The  application  of  a  firm  abdominal  binder  and 
the  administration  of  stimulants,  or  food  and  small  amounts 
of  wine,  together  with  the  assumption  of  the  upright  position 
after  the  correction  of  any  fetal  malpreseutation  will  gen- 
erally answer.  If  the  uterus  is  over-distended,  the  early  rup- 
ture of  the  membranes  will  generally  facilitate  the  delivery. 

What  may  cause  delay  in  the  second  stage  of  labor? 
How  should  such  a  condition  be  managed? 

Impaction  of  the  presenting  part  as  in  oversize  of  the  head 
or  undersize  of  the  pelvis,  and  failure  of  the  part  to  engage. 
This  is  a  more  serious  condition  than  the  former,  and  requires 
some  manual  or  instrumental  interference  on  the  part  of  the 
accoucheur. 

State  procedure  in  case  the  head  refuses  to  engage  in  the 
pelvic  brim. 

In  this  case,  if  the  disproportion  be  not  too  great,  axis- 
traction  forceps  should  be  applied.  In  more  marked  cases 
of  disproportion  version  is  indicated,  and  if  the  dispropor- 
tion be  very  great  symphysiotomy  or  Cesarean  section  is 
indicated. 


INDEX. 


Abdomen,  distended,  670 
regions  of,  177 
Abdominal  affections,  307,  488,  622 
aorta,  170,  209,  417,  433 
hernia,  567,  600 
muscles,  148 
palpation,  667 
ring,  207 
section,  726 
viscera,  165,  174 
waL,wounds  involving,591 
Abortion,  676,  677,  678,  732 
Abscess,  300,  583,  601,  603,  651 
mammary,  716 
of  liver,  467 
peritonsilar,  505 
pulmonary,  459 
retro-pharyngeal,  497 
Absorption,  236,  239,  247 
Accommodation,  224,  250 
Acetabulum,  152 
Acetanilid,  342,  369,  406,  506 
Acetates,  22,  383 
Acid,  40 

acetic,  15,  22,  45,  384 

arsenous,  379 

boric,  8,  322 

butyric,  137 

carbolic,  21,  33,  92,  130,  318, 

342,  345,  401 
carbonic,    75 
chromic,  10,  345 
citric,  132 
diacetic,  142 
gallic,  319,  356 
hippuric,  272 
hydriodic,  132 
hydrobromic,  2,  11,  132 
hydrochloric,  2,  11,  65,  80,  101, 

326,  338,  352 
hydrocyanic,  6,  138,  397 
hydrofluoric,  7 
lactic,  137,  400 
nitric,  11,  17,  52.  75,   76,  125, 
385 

(74 


Acid,  oleic,  358 

oxalic,  81,   138 
pyroligneous,  33 
saUcylic,  41,  317,  368,  387 
sulphuric,  11,  48,  76,  84,  121 
sulphurous,  11,  39,  122 
tannic,  70,  75,  bi,  365,  390 
tartaric,  70,  116,  123,  138 
uric,  23,  24,  38,  62,  68,  86,  92, 
102,  115,  135.  144,  500 
Acids,  39,  102,  397 
dibasic,  63 
monobasic,  63 
tribasic,  63 
Acetone,  145 
Acetous  fermentation, 
Aconite,  317,  343,  356,  359,  379,  510 
Aconitine,  dose  of,  34 
Acromegaly,  580 
Action,  chemical,  33,  50 
mechanical,  33 
physical,  50 
Adenoma,  601 
Adhesion,  30 
Adipose  tissue,  214,  290 
Adulteration,  121,  518.  534,  54H 
After  pains,  694 
Agglutinins,  300 
Air,  75,  267,  268,  519,  531,  5.34 

analysis  of,  99 
Albumin,  39,  47,  112,  144 

test  for,  25,  55.  85 
Albuminoids,   22 
Albuminuria,  73 

of  pregnancy,  674 
Albumose,  142 

Alcohol,   20,   22.   39.  47,   56,   71,   83, 
86,    89,    108,    113,    125, 
253,   336,   339,   519.   520, 
544 
drinking  of,  232 
freezing  point,  107 
methyl.  3.3,  126 
porccntnge    in    wines,    etc, 
20,  47 


746 


INDEX. 


Alcoholic  fermentation, 

intoxication,  461 
liquors,  39,  79,  518 
Alcoholism,  304,  336,  482 
Aldehydes,  71,  139 
Alimentary  canal,  188,  227,  239 

corrosion,  16 
Alkali,  16,  21,  41 
group,  128 
Alkaline  treatment,  386 
Alkaloids,   16,   23,  54,   69,   110,  119, 
129,  322,  325,  330,  336,  365,  373, 
384 
Allantois,  658 
Allotropism,  54 
•  Alloy,  61 

Aloes,  348,  382,  511 
Altitude,  effect  of,  546 
Alum,  91,  100,  348 
Aluminum,  44,  64 
Amalgam,   61 
Amenorrhea,  731 
Amid,   14 
Amins,  93 
Amnion,  658 
Amorphous,  3,  41,  105 
Ammonia,    109,    120,    124,    137,    138, 

343,  344,  380 
Ammonium,  119 

compounds,    10,    12,    41, 
68,  101,  115,  348,  366 
source  of,  41 
Amphiarthrosis,  157 
Amputations,    577,    581,    587,     603, 

605,  639 
Amyl  nitrite,  323,  334 
Amyloid  degeneration,  282,  298,  309 
Amylose,  33 
Analysis,  qualitative,  46,  80 

quantitative,  46 
Analytic,  94 

Anemia,  115,  285,  289,  294,  308,  488, 
731 
pernicious,    282,    289,    407, 
479,  493 
Anemic     condition,     remedies     for, 

314,  731 
Anesthetics,    35,   58,   316,   329,    362, 

403,  599,  601,  690 
Aneurysm,   295,   417,   496,   502,   566, 

580,  601,  602 
Angina  pectoris,  426,  443 
Angioleucitis,  310 
Angiomata,  293,  600 
Anhydride,  48 


Anhydrous,  131  •    • 

Anilid,  14,  42 
Anilin,  42,  138 
Animals,  as  food,  516 
Ankle  joint,  176,  178,  602 
Ankylosis  of  jaw,  554 

of  joints,  558 
varieties  of,  616 
Anodynes,  316 
Anospinal  center,  254 
Antagonist,  346 
Anthelmintics,  374 
Anthrax,  428 
Antidotes,  346 

chemical,  94 
general,    88 
physiological,  94 
for  arsenic,  11,  18,  19 
atropine,  396 
carbolic  acid,  21,   73, 

401 
caustic  alkalies,  73 
chloral,  328 
cocaine,  319 
copper  sulphate,  81 
hydrocyanic  acid,  123 
hydrofluoric   acid,   67 
hyoseine,  360 
iodine,  6,  77,  336 
lead,  9,  14,  49,  67 
mercuric  chloride, 125, 

130,  327 
mineral  acids,   16,  88 
morphine,  328 
nitric  acil,   28 
opium,   124 
oxalic  acid,  81 
phosphorus,     16,     17, 

123,  399 
silver  nitrate,  90 
stramonium,  87 
strychnine,      6,      117, 

328,  358,  508 
sulphuric  acid,  59 
tartar  emetic,  75 
zinc,  9 

zinc  chloride,  92 
Antimony,  38,  104,  141 
(Antipyretics,  357 
ivntipyrine,  352,  385 
Antiseptics,  360,  691 
Antitoxin,  29,  315.  365,  507,  5'66,  528 
Antrum  maxillas,  643 
Aorta,  186 
Aortic  aneurysm,  433,  496,  502 


INDEX. 


747 


Aortic  diseases,  462 

insufficiency,  229,  455 
regurgitation,  302,  455,  479 
stenosis,  455 
valve,  242 
Aphasia,  267,  492 
Aphonia,  267 
Apnoea,  235 

Apomorphine,  334,  387,  406 
Aponeuroses,  152 

Apoplexy,  328,  444,  461,  497,  501 
Apothecaries'  weight,  136 
Appendicitis,  174,  460,  473,  491,  575 
Appendix  vermiformis,  160,  184 
Aqua  ammoniae,  120 
fortis,  93,  119 
regia,  119 
Argentum,  18 
Argyria,  394 
Arnica,  398 
Arsenic,  18,  31,  34.  71,  76,  113,  141, 

314,  326,  364,  379,  406,  416,  511 
Arterial  pulse,  235,  433.  453 
Arteries,  250,  274 

aorta, 

axillary,  158 

basilar,  182 

brachial,  156,  167 

carotid,   149,   ]83,   613 

celiac  axis,  203 

cerebral,  167 

coronary,  304 

degeneration  of,  296.  297, 
309 

femoral,  161,  165,  598 

intercostal,   167 

internal  carotid,  178 

internal  iliac,  205 

ligation  of,  179,  562,  570, 
596,  597,  598,  604,  605, 
606,  613,  615 

meningeal,  176,  286,  568 

of  bladder,  179 

of  Circle  of  Willis,  Zl2 

of  hand,  190 

of  heart,   168 

of  kidneys,   165 

palmar  arch,  174 

popliteal,   165,  203,  606 

post-tibial,  198 

pressure  of,  401 

pulmonary,  208 

structure   of,   247 

subclavian,  164,  615 

tibial.  165 


Arteries,  ulnar,  206 

Arthritis  deformans,  301 

Arvtenoid  cartilages,  "205 

Asafetida,  335 

Ascites,  295,  464,  634,  670 

Asepsis,  691 

Asphyxia,  217,  263,  697 

Assimilation,    253 

Asthma,  327,  479,  496 

Astasia,  410 

Astigmatism,  273 

Astringent,   315.  337,  376,  379 

Atavism,  233 

Atheroma,  294 

Atmosphere,  composition  of,  38 

Atom,  definition  of,  1,  26 

Atomic  theorv,  53 

weight.  3,  36,  48.  89 
Atresia,  741 

Atrophv,  292,  298,  482,  615 
Atropine,  16,  54,  100,  322.  323.  332, 

344,  349,  396,  406.  511 
Attraction,  forces  of,  29 
Auditory  apparatus.   155 

vertigo,  259 
Aural  labyrinth.  203 
Ausculation,  421,  455,  475.  476,  668 
Autopsy,  83 
Axilla,  170 

Bacteria.    239.    281,    282,    297,    302. 
309,  521.  699 

bacilli,  310,  699 

diplococci,  309 

micrococci.  310 

spirilla,  310 

staphvlococci,  309,  699 

streptococci.  309.  699 
Bag  of  waters,  686 
Baking  powder,   10,   121.   133 
Ballottement.  666 
Balsam  of  Peru.  324 
Barbers,  hygiene  of.  550 
Barium,  76 
Barley  water,  358 
Barometer,  103 
Base,  definition  of,  46 
Basic  radical,  46 
Rassini  's   operation.   582 
Bathing.  533 

Baths.  515.  531,  533,  .546,  549 
Belladonna.    16,   323.   326,   337.   347, 

361,  372.  375,  385.  509 
Benzene.  15.  110 
Benzoin,   384 


748 


INDEX. 


Bi,  definition  of,  61 
Bile,   21,    22,   44,    72,   96,    120,    134, 
216,  251,  276 
duct,  occlusion  of,  310 
Biliary  calculi,  78,  423,  427 

lithiasis,  424 
Bilirubin,  21,  71,  141 
Binary  compounds,  40,  47 
Birth-canal,  injuries  to,  742 
Bismuth,  76,  102,  136,  337,  366,  378 
Bladder,  163,  165,  166,  179,  196.  597 
atony  of,  638 
injections  for,  389 
Blisters,  319 
Blood,  alkalinity  of,  2/5 

circulation  of,  156,  226.  235, 
238,  248,  274,  297 

coagulation  of,  217,  240,  269 

composition  of,  233,  246 

corpuscles,  221,  247.  252.  255, 
258,  266 

description  of,  270 

during  gestation,  663 

expectoration  of,  485 

extravasated,   309 

function  of,  221 

how  purified,  272 

in  gout,  295 

in  rheumatism,  475 

plasma,  307 

pressure,  236,  241,  385,  417 

quantity  of,  219 

reaction  of,  22,  72,  242 

stains,  262 

supply,  170,  211 

vessels,  224,  247 
Blow-pine,  38,  110 
Blue  pill,  384 

vitriol,  43 
Blushing,  235 
Body,  composition  of,  46,  236 

sensitive  areas  of,  213 
Boiling  point,  130 
Bones,  clavicle,  166.  614 

external  malleolus,  173 

femur,  646 

frontal,  174 

how  nourished,  270 

humerus,  150,  156,  161 

hyoid,  197 

inflammation  of,  298,  595 

occipital,   154 

of  ankle  joint,  176,  178 

of   foot,   154 

of  hand,  182 


Bones    of  head,   152 

of  heel,  168 

of  inferior  maxillary,  625 

of  pelvis,  169 

ossa  innominata,  195 

parietal,  221 

patella,  169 

radius,  170 

sternum,  196 

superior  maxillary,  197 

temporal,  189 

vertebrae,  173 

to  promote  growth  of,  399 

Wormian.  200 
Borax,  8,  9,  43,  322.  397 
Boroglycerid.  67 
Boron,  95 

Brachial  plexus,  147 
Brain,  anemia  of,  294 

arachnoid,  262 

cerebellum,   216 

cerebrum,  212,  219,  260 

convolutions  of,  190 

corpus  callosum,  209 

cortex  cerebri,  222 

dura  mater,  175,  262 

fissure  of  Rolando,   161,  2i»<, 
212 

fissure   of   Sylvius,   161,   207, 
212 

fourth  ventricle,  179 

function  of,  262 

gray  matter  of,  276 

hemorrhage  of,  4V9 

lobes  of,  161,  183 

malar,  179 

medulla  oblongata,  201,  232 

membranes  of,  162,  262 

motor  area  of,  260 

pia  mater,   182,  262 

pons  varolii,  164 

seat  of  special  senses,  259 

tumor,  412,  636 

ventricles  of,  180 
Brand  treatment,  489 
Brandy,  39 
Breasts,  663,  671,  673,  736 

removal  of,  581 
Breathing,  280,  480,  481,  502 
Bright 's  disease, 
Bromides,  313,  335,  382,  403 
Bromine,  12,  35,  39,  53 
Bromism,  338 

Bronchial  breathinar,  463,  481 
tubes,  164,  224 


INDEX. 


749 


Bronchitis,   285.  341,   387,   422,   423, 

458,  481,  498 
Bronehorrhea,  390,  494 
Broncho-pneumonia,  49(i 
Brucine,  317 
Bryonia,  340 
Bubo,  620 

Bubonic  plague,  3fl(i,  517,  549 
Buehu,  351,  353 
Buckthorn,  382 

Building,   hvj^iene   of,    5 IS,   529,   547 
Bunions,  577 
Bunsen  burner,  39 
Burns,  297,  555,  fi02 
Bursitis,  577 
Butter,  24,  515 

Cacao  butter,  320 
Caffeine,  329,  359,  508 
Calabar  bean,  325,  337,  396 
Calcific  metamorphosis,  308 
Calcium.  2,  111,  380 
carbide,  8 
chloride,   338 
compounds,  8,  10 
Calculi,  biliary.  78.  423.  427.  442,  458 

urinary,   72 
Calculus  formation,  62 
Calomel.  10.  52,  377 
Camphor,  324,  326,  333.  384.  396 
Camp  hospital,  528 
Cancer.  453    (See  carcinoma) 

of  the  stomarli.  446.  417 
Candle  flame,  chemistry  of.  118 
Cannabis  Tndica,  337.  367.  511 
Cantharides.  322 
Cantharis.   353.  388 
Capillaries.   226.  250..  274 
Capillary  attraction,  93,  129 
Capsicum,  342,  380 
Caput  succedanum.  683 
Carbohydrates,  19.  56.  71.  253,  525 
Carbolic   add.   21.   33.    92.    130.   318, 

342.   346.  401.  509 
(;arbo  lifjni.  329 
Carbon.  2,   14.  72.  99 

oxides  of.  52.  57.  99.  112.  119 
Carbuncle,  (501 
Carcinoma.   284.   287,   288,  553,   581, 

597,  601,  641,  642,  738 
Cardamon,   331 

(^ardio-inliil)it()rv  centers,  269 
•  Varies,  291,  610" 
Cartilage.  230.  266.  301 
CnscTra  sagrada,  342.  359,  510 


(-aseine,  21 

Caseinogen.  21 

Castor  oil,  383 

Castration.  609 

Casts  in  urine.  2^4 

Catalepsy,  414 

Cataphoresis,  403 

Catarrhal  inflammation.  291 

Cathartics,  327,  360,  381 

Catheterization,  694 

Caustic,  9 

Cecum,   177 

Celiac  axis,  203 

Cell  growth,  263,  266 

Cells  of  body,  233,  256.  257.  266,  290 

Cemeteries,   532 

Cerebral  cortex.  277 

hemorrhage,   281,   306,   328. 
434,  444,  475.  479.  497 

softening,  290 

tumor,  484 

veins.  199 
('erebro-spinal   fever.   288.   451,   463, 
471 
meningitis.  407.  44.>. 
474 
Cerumen,  impacted,  621 
Cervical  caries,  610 

carcinoma,  73s 

vertebrae.    152 
<  'ervix  uteri.   690 
Ccsarian  section,  725 
Chancre,  420,  644 
Chancroid,  42(i,  5S2.  640,  644 
Charcoal,  381 
Chemical  action,  82 

affinity.  2 

analysis,  46 

combustion,   127 

suffixes,  26 
Chemisni,  2 
(  hemistry,   1,  37,  79 
Chest   in   res|)iration,   25S 
Ciieyii(>-Stokes    rcsjiiration,    416.    4s:c 
Cjiicken-Dox,  459 
Chills,  215 

Chloral.  21.  65,  77.  !»7.  .ilC).  32S.  373. 
403.  509 

poisoning,  381,   406 
Clilorides,    196 
Cldiirinated  liu'o,  51,  5(i 
Chlorine.  6.  9.  12,  13.  14,  35.  3S.  43, 

60,  .S2 
Chloroform,  20,  21.  6.5.  8.S,  87,  88.  95,. 
113.  35S.  363.  372.  402.  404 


750 


INDEX. 


Chlorosis,  407,  473,  503,  731 
Cholagogue,  334 

Cholera,  Asiatic,  436,  462.  479,  528, 
537 
morons,  430.  462 
Cholesterin,  21,  257 
Chonclrin,  272 
Chorda  tympani,  218 
Chorea,  424,  478 
Chyle,  217,  245 
Chyme,  217 
Chromium,  140 
Chrondroma,  595 
Cicatricial  changes,  296 
Ciliary  processes,  210 
Cinchona,  16,  317,  367,  377,  511 
Cinnamon,  372 
Circle  of  Willis,  180,  212 
Circulatory  system,  156,  226,  361 
Cirrhosis,  425 
Cisterns,  524 
Clavicle, 

Circumcision,  620 
Climate,  524,  531 
Club-foot,  562.  571,  572.  616 
Coal-gas,  393 
oil,  128 
tar,  98,  377 
Cocaine,  54,  319,  344,  365,  398 
Codeine,  23,  353 
Cod-liver  oil,  371 
Coffee,   87,   253,  543 
Cohesion,  8,  30 
Coition,  painful,  742 
Colchicum,  322,  333,  342,  394,  511 
Colds,  preventive  hygiene,  537 
Colic,  372,  486,  499 
Collodion,  374 
Colloid  degeneration, 
Collyrium, 
Colocynth,  333,  401 
Color  blindness,  262 
sensation,  237 
Colostomy,  578 
Columnae  carneae,  275 
Coma,  407,  461,  630 
Combination,  chemical,  127 
Combustion,    38,    82,    112,    113,    116, 

513 
Comma  bacillus,  283 
Complemental  air,  268 
Compound,  1 
Compounds,  1,  80,  98,  131 
Congestion,  564,  576 
Conium,  326 


Connective  tissue,  147 
Constipation,   343,  522 
Convallaria  majalis,  329 
Cooking,  effect  of,  240,  535 
Copaiba,  402 
Copper,  12,  18,  80,  82,  313,  397 

sulphate,  16,  313,  333,  397 
Corpus  luteum,  261,  279 
Corrosive  sublimate,  52,  314,  343 
Coryza,  467 
Cough,  372,  419,  422 
Coxa  vara,  646 
Craniotomy,  725 
Cream  of  tartar,  101,  384 
Crede's  method  of  placental  delivery, 

687 
Cremation,  514,  545 
Creosote,  353,  375,  388 
Cretinism,  289 
Croton  oil,  313,  345 
Croup,  397,  423 
Crystalline,  definition  of,  3 

lens,  162 
Crystallization,  25 
Crystals,  formation  of,  34 
Cubebs,  345 
Curare,  353 
Curettage,  714 
Cyanogen,  53,  64 
Cyanosis,  487 
Cystitis,  438,  740 
Cystocele,  730 
Cysts,  282,  632 

Dead,  disposal  of,  514 
Death,  244 

changes  in  body  after,  46 
Death-rate,  average,  516,  528,  544 
Decantation,  131 
Decay,  106,  116,  123 
Decomposition,  81,  105,  114,  134 
Defecation,  254 

Degeneration,  285,   288,  292,  298 
Deglutition,  217 
Deliquescent,  89,  131 
Delirium  tremens,  471,  493 
Delusion,  500 
Dementia,  414 
Depressants,   386 
Dermoid  cysts,  632 
Dextrine,  15,  103 
Dextrose,   15 
Diabetes  insipidus,  434 

mellitus,  21,  36,  429,  434, 
453,  466,  473,  522 


INDEX. 


751 


Diabetics,  77 

Diagnosis,   105,   409,   410,   416,   422, 

464 
Dialysis,  84 
Diapedesis,  256,  423 
Diaphoretics,   321,   327,   335,  391 
Diaphragm,  161,  215,  220,  253 
Diarrhea,  372,  381,  402,  444 
Diarthrosis,  157 
Diastase,  15 
Diet,    122,   214,   216,   241,    263,   275, 

466,  522,  531,  540,  541 
Diffusion,   8 
Digestion,   220,   225,   233,   238.   239, 

241,  243,  248,  268,  278 
Digestive  secretions,  222,  228 
Digital  examination,  416 
Digitalis,    318,    347,    355.    359.    364, 

385,  387,  508,  511 
Diphtheria,  283,  365,  418,  438,  459, 

479,  507,  521,  528,  534,  535,  542 
Diphtheritic  exudation.  289 
Diseases,  infections,  290,  514,  550,  551 

preventable,  517 
Disinfectants,  51,  70,  130,  533,  535 
Disinfection,  527,  537 
Dislocations.  603,  610,  619,  640,  642 
of  elbow,  588 
of  forearm,  645 
of  head  of  femur,  586 
of  hip,  605,  629 
of  humerus,  627 
of  inferior  maxilla.  608 
of  knee,  633 
of  shoulder,   564,    590, 
608 
Distillation,  5,  10.  32,  50,  94 
Diuretics,  320,  327,  377,  383,  508 
Divisibility,  chemical,  2 

mechanical,  2 
Donovan  's  solution,  333 
Dosage,  397 

for  children,  388 
Dover's  powders,  349 
Drink,  529 

Dropsy,  307,  361.  464,  480,  488 
Duboisine,   330 
Ductus   communis   choledochus.    147. 

220,  251 
Duodenal  ulcor,  417 
Duodenitis,  411 

Duodenum,  nbsorption   from,  236 
Duke  's  disease,  506 
Dura  mater,  175.  262 
Oyad,  2,  5 


Dysentery,  381,  460 
Dyspareunia,  742 
Dysphagia,  235,  433,  579. 
Dyspnea,    235,   422 
Dystocia,  702,  703 

Ear,  161,  261,  263,  278,  604 

diseases  of,  487.  506.  599.  609. 
621 
Ecbolics,  321 
Eclampsia,  713,  714 
Ectopic  pregnancy,  679,  680 
Eczema,  288,  306,  415 
Edema,  282,  433.  445,  481 
Effervescence,  74 
Efflorescence.  74 
Elaterin,  375 
Elbow.   165 

joint,  185,  588 
resection  of,  636 
Electric  battery,  4,  124,  219 
current,  4 
light,  95 
Electricity,  82,  111 

static,  10 
Electrolvsis,  131 
Element,  112 

definition  of,  43,  80.  98 
combination  of,  40 
groups  of,  3,  137 
in  human  bodv,  100 
Embolism,  286,   294,   500 
Plmbryo,  human,  663 
Embrvotomv,  725 
Emeti'cs,  327,  362 
Knimenagogue,  325 
Empyema,  459 
Emulsification,   251 
Emulsion,  110,  354 
p]ncephalon,  230 
Endemic  diseases,  513 
Endocarditis.     408.    434,    445.    447, 

460,  480,  507 
Endocardium.   164 
Kndometrium.  diseases  of,  676.  720 
Rndosmosis,  66 
Endothelium.   149 
Enteric   fever,  460 
i  Knteritis.   253,  454.  460 
!  P'pidemic  diseases,  513 
Kpiglottis.  230 
Hpilepsy.  429.  458,  487 
Episiotomy.  6S9 
Epispadias,  611 
Epistaxis,  627 


752 


INDEX. 


Epithelial  secreting  surfaces,  246 

Epithelioma,  282,  418,  420 

Epithelium,  203,  216,  264 

Epsom  salts,  92,  96 

Equations,  chemical,  5,  6,  8,  13,  14, 
16,  17,  18,  19,  21,  28,  33,  36,  41, 
42,  47,  49,  54,  55,  56,  60,  63,  66, 
68,  73,  74,  76,  81,  82,  83,  90,  91, 
96,  97,  102,  104,  105,  107,  109, 
113,  118,  119,  121,  124,  125,  126, 
128,   133,  135,  136,  137,  139.  141 

Erectile  tissue,  248 

Ergot,  325,  354,  390,  511,  692 

Eruptive  fevers,  449,  452,  459,  468 

Erysipelas,  412,  426,  465,  623 

Erythema,  412  . 

Erythroxylon,  365 

Escharotics,  360 

Eserine,  325,  336,  373 

Esmarch's  operation,  554 

Esophageal  stricture,  430,  599 

Esophagus,  180,  184 

Ether,  22,  83,  85,  89,  125,  134,  316, 
358,  403,  404,  405 

Ethers,  compound,  45 

Ethyl  hydrate,  113 

oxide,  109,  358 

Eucaly|3tus,  389 

Eustachian  tube,  161,  261 

Eutocia,  702 

Evaporation,  35 

Exanthemata,  478,  485 

Excipient,  356 

Excreta,  disposal  of,  539,  550 

Excretion,  253,  257,  274,  72< 

Exercise,  258,  541 

Exhumations,   533 

Exophthalmic  goitre,  412,  447 

Exophthalmos,   610 

Expectorant,  341 

Extracts,  376 

Eye,    178,    180,    198,    203,    204,    210, 
250,  266,  319,  526 
cornea   of,   278,   407 
eneucleatiou  of,  617.  626 
iris   of,   193,  407 
movements   of,    252 
paralysis    of,    413,    484 
pupil  of,  232 
refractory  media  of,  242 
retina  of",  213,  249,  258,  276 

factory  hygiene,  517 
Fallopian  tubes,  174 
Faradic  current.  97,  111,  219 


Fats,  24,  126,  223,  253 
Fatty  degeneration,  292 
infiltration,  292 
metamorphosis,  286 
Favus,  308 
Fecal  impaction,  507 
Feces,  232,  402,  486,  499.  507,  525 
Feeding.  358 

rectal,  244 
Fecundation,  657 
Fehling's  test,  25.   88,  102,  143 
Female  reproductive  organs,  653 
Femoral  hernia.   184 
Fermentation,  33,  59.  74,  77,  113,  116 
Ferric  salts,  11,  13,  54 
Ferrous  salts,  8,  9,  13,  350 
Ferrum  redactum,   109 
Fertility,  676,  742 
Fetal  heart  sounds,  666 
Fetus,  664,  665,  666.  672,  676,  694 
Fever,   21,  279,  288 
Fibrin,  272 

Fibrinous   deaeneratinn,    288 
Fibromata,  292 
Fibrous  tissue,  284 
Filth  diseases. 
Filtration,  35 
Firedamp,   75 
Fissure  of  Rolando,  161 

of  Sylvius,  161,  167 
Fistula,   609,'  617 

in  ano,  565,  J66,  617 
Flame,  chemistry  of,  118 
Fluid  extracts,  380 
Fluorine,  12,  35,  67,   140 
Fontanels,   665 
Foods,  215,  216,  218,  219,  222,  225, 

226,  229,  240,  242,  250,  358,  516. 

525,  529,  535,  536,  543 
Foramen   ovale.   209,   278 
Foramina  of  skull,  153 
Forearm,  amputation  of,  179 
Forceps,  use  of.  720,  721,   722,   723, 

724,  733,  744 
Forests,  effect  of,  525 
Formaldehyde,  51,  139 
Formula^  30,  49,  74,  93,  116,  120,  133 
Fourth  disease,  506 
Fowler's  solution,  113,  333,  394 
Fractures,   561.   607.    608,   619,   623, 
635,  638,  643,  647 
clavicle,  614 
femur,  586.  594.  635 
forearm,  577 
inferior   maxilla,    625 


INDEX. 


753 


fractures,  humerus,  i)64 

nasal  bones,  569 

patella,  593 

Pott's,   554 

ribs.  629 

skull.  ."ir)7.  561,  563,  592, 
622 
Freezing,   107 
Fruits,  522 

Funis,  prolapse  of,  719 
Furuncle,  601 

Galactogogue,  392 
Galactorrhea.  716 
Gall  bladder,  179 

stones,   78,   436 
(ralvanic  cell,  5.  50 

definition  of.  3,  10.  Ill 
Gamboge,  401 

Gangrene,  286,  292,  469,  649 
Garbage,  disposal  of,  541.  552 
Gas,  7,  80 

coal,  393 

definition  of,  37 

illuminating,  51,  73,  120 

nitrous  oxide,  118,  404 

olefiant.  32 

sewer.  515,  544 
Gaseous  elements, 
Gastralgia,  448 
Gastric  cancer,  453 

juice,  21,  22,  142,  242,  246, 

262 
ulcer,  453,  457,  505 
Gastritis,  416,  468 
Gastro-duodenitis,   336 
Gat^rotomy.  612 

Gelsemium,  331,  377,  .382,  383,  511 
Genitalia,  566 
Gentian,  380 

Genupectoral  posture,   719,   736,  743 
Genu  valgam,   611 
Germicide.   121.   351 
fJerm   theory.   527 
(iestation,  663 
Giant  cell,  597 
Glands,  ductless,  257 

excretory,    274 
of  small   intestine,    172 
undetonninod    functions    of. 
261 
(Jlauber's  salt.  96,  324 
Glaucoma,   414,    637 
Gliomata.  610 
(tlobulins.  47 

48 


Glottis,  edema  of.  433 
Glucose,  33,  41,  47.  52,  59,  109 
Glucosides,   357 
Glycerin,  19,  45,  111,  398 
Glycogen,  49.  216,  230 
Glycosuria,  25 
Goitre,  447 

Gold,  2,  38    82.  128,  o22 
Gonorrhea.  582 

in  obstetrics.  716,  740 
GonoiTheal   ophthalmia,   293 
Gossypium,  365 
Gout,  294,  295.  423,  496,  498 
Gram,   7 

Gravitation.  8,  48 
(Jroin,    598 

Guaiacum,  370,   373.   382 
Guarana,  350 
Gum  arabie.  384 
Gun-cotton,  15.  91 
Gunshot  wounds,  591 

Hair  follicle,  200 

Halogens.  12,   43 

Haloid  salt,  117 

Hallucination,  500 

Hamamelis,  353 

Hammertoe,   631 

Hamstring   musole,    167 

Hare-lip,  627 

Haversian  svstem.  204 

Hay  fever,  503 

Hearing,  organs  of,  241,   263 

Heart,  apex  beat  of.  253 
arteries    of.    168 
cardio-inhibitory  center.   269 
cohimnae  carneae.  275 
description  of,  173 
dilatation  of,  286.  462 
displacement   of.   421 
effect     of    exereLse    on,     258, 

519 
fatty  changes   in,   287 
foramen   ovale  of,   209,  278 
hypertrophy  of,  286.  462 
mitral  regurgitation.   409 

stenosis,    472 
myocardial   degeneration.   -WA 
palpitatiiin  of,  437 
rate  of,   234,  243.  251 
ratio  of  beats  to  respiration. 

261 
remedies,  34.3.  344.  347.  351, 

367,  371,  373 
revolution  of.  223 


754 


INDEX. 


Heart    sounds,    263,    267,    411,    455, 
471,  477,  483,  666 
topography   of,   421 
valves  of,  411 
valvular     diseases     of,     286, 

302,  462,  499 
ventricles  of,  ±49,  154 
weak,training  for, 
Heating  of  houses,  525 
Heat,  latent,   5 

production,  257 
prostration,  462,  529 
specific,  5 
Hectic  fever,  308 
Hectogram,  30 
Heel,  bones  of,  168 
Hematemesis,   430,   498 
Hematics,   354 
Hematocele,  711 
Hematosalpinx,   729 
Hematoxylon,  375 
Hematuria,  413,  490 
Hemiplegia,  214 
Hemoglobin,  24,  96,  234 
Hemophylia,  429 
Hemoptysis,  470,  498 
Hemorrhages,  219,     297,     402,     423, 
439,   568,   584,  599, 
641 
cerebral,      281,      306, 
328,   434,  444,  475, 
479,  497 
gastric,  408 
from  the  liver,  554 
in  obstetrics,  701,  720 
of    the    bowels,    433, 

493 
pulmonary,  408,   439 
Hemostatics,   352 
Hemothorax,  452 
Hepatitis,   432 
Hepatization,  414 
Hernia,  566,  567,  582,  589,  590,  600, 

602,  612 
Herpes,  420 

progenitalis,  644 
zoster,   415,   446 
Hiccough,  220,  344 
Hip  ioint,  183 
Hospitals,   516,    528 
Humerus,  150,  156,  161 
Humidity,  effect  of,  548 
Hunger,  220 
Hydatid  pregnancy,  659 
Hydracids,  101 


Hydrargyri  iodidum   rubrum,   367 

oxidum  fiavum,  13 
Hydrargyrism,   368 
Hydrargyrum  cum  creta,  366 
Hydrastis,  369 
Hydrate,  40 
Hydride,    117 
Hydro,  definition  of,  61 
Hydrocarbon,  87,  97 
Hydrocele,   602,   620 
Hydrocephalus,  427,  468,  717 
Hydrogen,  2,  34,  38,  39,  42,  43,  74, 
111,   119 
dioxide,   16,  24,   56,   120, 

124,  310 
sulphide,    11,   40,   61,    75, 
104,  126 
Hydrogogue,  334 

Hydronephrosis,   494 

Hydrophobia,  559 

Hydrosalpinx,   729 

Hydrothorax,  465 

Hydroxide,  130 

Hygiene,  513 

Hygrometer,  103 

H'yoscine,   336,  356,  360,  376 

Hyoseyamine,    16,    336,    511 

Hyoscyamus,  16,  365 

Hyper,  definition  of,  61 

Hyperemesis,   669 

Hyperemia,  285,  308 

Hypermetropia,  273 

Hypertrophy,  286,  462,  641 

Hypnotics,   359 

Hypochondriac  region,  154,  176 

Hypodermic  medication,  316,  381 

Hypodermoclysis,  391 

Hypospadias,  611 

Hypostatic  inflammation,  308 

Hysterectomy,  700,  725,  739 

Hysteria,  36,  458 

Ice,  526 

artificial,  529 

natural,  529 
Ichthyol,  355 
Icterus,  295,  477 
lleo-cecal  valve,  178,  231 
Illuminating  gas,  51,  73,  120 
Illusion,  500 

Immigrant  inspection,  546 
Immunity    from    disease,    281,    283, 

514  523 
Imperforate  hymen,   727 


INDEX. 


755 


Incompatibility,   110,  318,  325,   329, 

361,  375,  386 
Incubation,   552 
Indestructibility,  127 
Indian  hemp,  337 
Indican,  143 
Infant,  care,   695 

feeding,  514,  532,  551,  695, 
734 
Infantile  paralysis,  487,  652 
Iniarct,   294 
Infectious    diseases,    290.    514,    550, 

551 
Infiltration,  285,  289,  292 
Inflammation.  36,     288,     290,     291, 
294,   298,   299,   306, 
576,   595,   627.   628, 
644 
infective,  290,  729 
Inflammatory  fever,  586 
Influenza,  470 
Inguinal  canal,   164,   168 

region,   500 
Inoculation,  528 
Inorganic  compounds,  96 
Insemination,  656 
Insolation,  426,  462,   501 
Insomnia,   334 
Intercostal  neuralgia,  467 
Intermittent   fever,   364.   411.   468 
Internal  capsule,  214 
Internal  hamstrings,  167 
Intervertebral   substance,   210 
Intestine,  large,  248,  267 
small,  172,  248 
Intestinal  bacteria,  239 
colic,  372,  499 
glands,  255 
indigestion,   364 
obstruction,    443,    597.    633, 

650 
movement,  2.54 
peristalsis,   382 
villi,   255 
Intussusception,   602 
Involution,   693 
Iodides,   130,  376 
Iodine,  4,  6,  8,  12,  35,  .332,  336 
lodism,  369 

Iodoform,   .53,   354,   368 
Ions,  definition  of,  1,  139 
Ipecacuanha,    329,    359 
Iris  366 

(of  eye),  193 
Iritis,  407,"  414 


Iron,  38,  73,  76,  82,  115,  314 

comnniiPfls    of,    12,     99,     115, 

329,  356 
group,   128 
reduced,  109 
j  Ischemic  paralysis,  297 
Ischio-rectal  abscess,    553,    591,    651 

fossa,  149 
Isomerism,  46,  62 
Isomorphous,   3,   105 

Jaborandi,  318,  342 

Jaborine,  318,  384 

Jaboridine,  318,  384 

Jalap,  324,  371,  382 

.law,  excision  of,  605 

Jervine,  395 

Joints,  558,  602 

knee,  202,  211 
tuberculous,   296.   310 

Juniper,  395 

Keratitis,  407 

Kidneys,  14J,    171,    175,    225,    245, 
280,  356,  607 

circulation  of,  233 

colic  of,  486 

floating,  646 

degeneration  of,     05 

prolapsed,  420 
Koumiss,   366 
Kousso,  402 

Knee-chest  posture,  719,  736,  743 
Knee  joint,   202,   211,   557 

Labor,  659,  681,  685,  686,  703,  I'^o, 

732,  734 
anesthetics  in,  690 
care  of  mother  after,  693 
delayed,  708,  736,  743 
diagnosis   of,   681 
duties  of  accoucheur,  692 
management    of,    681,    687, 

689,    690,    691,    692,    709, 

726,   736,    737.    742.   743 
mechanism  of,  681,  683,  684, 

685,    704,    70.5,    706,    707, 

708,    712,    720,    721,    722, 

723,  733 
pathology  of.  691.   698,   732, 

73.5,  7.38 
pains,  6S1,  682 
precipitate,    708 
premature,   676.   679,   732 


756 


INDEX. 


Labor,  preparation     for,     673,     680, 
688,  691 
presentations    in,    683,     684, 
685,    703,    704,    705,    706, 
707,    708,    725,    732,    733, 
734,  737 
prolonged,  708 
stages  of,  681,  682,  686,  687, 

736,  744 
twin,   718 
Lachrymal  duet, 

gland,   202 
Lactation,  278,  696 
Lactose,  59 
Lactucarium,    342 
Lanolin,  368 

Lardaceous    degeneration,    298 
Laryngismus  stridulus,  415,  421,  477 
Laryngitis,   413 
Larynx,  163 

intubation  of,  651 
stenosis  of,  623 
ventricles  of,  165 
Latent  heat.  5,  47 
Lateral  sinus,  189 
Laughing  gas,  118 
Laws  of  combination,  40 
Laxative,  381 
Lead,  6,  18,  67,  337,  341.  383 

poisoning.   14,  431 
Leontiasis  ossia,  580 
Leucin,  272 

Leucocyte  count,  410.  435 
Leucocytosis,  504 
Leucomaines,  261 
Leukemia.   285.  435.   448 
Life,  244,  526 
Lighting,  549 
Lignum  vitae,  370 
Lime,  380 

water,  392 
Limonis  sulcus,  374 
Linimentum  calcis.  371 
Linea  alba,  199 
Linum,  369 
Lipomata, 
Liquid,   7,   ..7 

Liquor  ammonii   acetatis.   343 
amnii,  658 
calcis,    383 
pota.ssi  arsenitis,  354 

hydroxidi.  319 
eodii  arsenitis,  354 
Liquors,  distilled,  36.   79 
fermented,  36.  79 


Liquors,   malt,   36.   68.   79 
Liter,    7 
Litharge,  67 
Lithemia,  477 
Lithotomy,   606,  632 
Liver,  147,  174,  230,  274,  280 
abscess  of,  467 
amyloid,  303 
atrophy  of,  298,  310 
cirrhosis  of,   283,   288,  425 
hemorrhage  of,  554 
hyperemia  of,  299 
percussion  of,  476- 
Lobelia,  313,  397,  511 
Locomotor  ataxia,  293,  476,  495 
Lotio  hydrargyri  flava,   340 
nigra,  349 
Lumbar  puncture,  649 
Lunar  caustic,  10,  93 
Lungs,  175,  202,  224,  229,  239,  245, 
414 
cavity  of,  452 
congestion  of,  472 
gangrene  of,  469 
Lupus,  418,  617 

Lymph,  240,  245,  251.   299,  543 
Lymphadenitis,  307 
Lymphangitis,  310 
Lymphatic  glands,     148,     207,     209, 
299,  305,  476 
system,  247,  264 
Lymphocytosis.  504 
Lymphorrhagia,  297.  299 

Magnesia,  16,  395 

sulphate,  510,  511 
Malaria,  413,  468 

hygiene  of,  513 
Malignant,   295 
Malleability,  66 
Malleolus,  external,   173 

internal.   154 
Malt,  118 

Maltose,   15,  59,   118 
Mammary  abscess,  716 

glands,  557,  671,   715 
Man,  typical,  532 
Manganese,  314,  370 
Manure,   disposition  of,   534 
Marble,  43 
Marsh's  test,  31 
Mass  of  matter,  98 
Mastication,   278 
Mastitis,  715 
Mastoiditis.    415 


INDEX. 


757 


Materia  medica,  definition  of,  330 
Matter,  properties  of,  7,  114 

states,  89,  215 
Maxillary  sinus,  186 
Measles,  419,  449,  452.  454,  464,  479, 

516,  539 
Meat  inspection,  548 
Meconium,  666 

Medicines,  introduction  into  circula- 
tion,  346 
Mediastinum,   195,   207,   210 
Medulla  oblongata,  201,  232 
Meibomian   glands,   156 
Melancholia,  414 
Melanosarcoma,  283 
Membrana  tympani,  263,  55S 
Membranes,   mucous,  234,  259.  260 
serous,   259 
synovial,  259 
Meniere's    disease,   259 
Meningitis,  283,  296,  407,  443,  463, 

469,  474,  476 
Menopause,  654,  732 
Menorrhagia,  741 
Menstruation,    279,    380,    654,    657, 

675,   696 
Mentha  piperita,  368 
Mercury,  30,    76,    80,    97,    ]00,    105, 
112,  364,  366,  376,  384, 
388,   389 
freezing  point,   107 
chlorides    of,    10,    13,    84, 

97,  134,  314,  327,  340 
iodides  of,  132 
Mesentery,  172 
Metabolism,  215,  218 
Metals,   18,  48,  76 
Metamcric,  62 
Methane,   62 
Meter,  7 

Metric  system,   78,   104,  405 
Metrorrhagia,  741 
Jficroscope,  464 
Micturition.  228 
Miirraine,  494 
^Tilium,  019 
Milk,  adulteration  of,  72,  534 

arresting  secretion  of,  339 
composition  of,  21,  23,  72,  70, 

130 
cow's,  23,  528,  551,  552 
diseases  conveyed  hy,  5li,  544 
human,  23,  71,  in 0,"  237 
inspection  of,  548 
modified.   734 


Milk,  sonring  of,  23,  72,  77 

sterilized,  117,  528,  547 
sugar  of,  393 
Mineral  water,  27,  65,  90,  122,  135 
Miscarriage,  676 
Mitral  regurgitation,    409,    499 

stenosis,  302,  472 
Mixture,  definition  of,  1,  80 
ilolecule,  definition  of,  26 
Monad,  2,  5 
Morbus  coxae,   558,    612 

Brigbtii,  56,  289,  674 
Morning  sickness,  669 
Morphine,  23,  54,  87,  32<J,  349,  403, 

511 
IVTortification,   582 
Motor  impulse,  277 
Mouth  breathing,   214 
hygiene  of,  535 
Mucin,  86 

Mucoid  degeneration,  285 
Mumps,  446 
Muscles,  99 

abdominal,  148 

affections  of,  243,  613 

atrophy  of,  296 

classes  of,  151,  204,  260 

compressor  urethrae,  152 

contraction  of,  259 

deltoid,  182 

fatigue,  209 

gluteus  maximus,  176,  210 

internal  oblique,  148 

involuntary,  240 

masseter,  210 

of  back,  205 

of  back  of  leg,  178 

of  calf  of  leg,  150 

of  deglutition,   170,  217 

of  elbow  ioint,  211 

of  eye,  252 

of  femur,   150 

of  foot,   210 

of    forearm,    151 

of  head,  209 

of  humerus,  155 

of  neck,  l,c9 

of  orbit,   152 

of  male  perineum.  17S 

of  mastication,   170 

of  patella.   169 

of    scapulohumeral     ioint, 
191 

of  tondo  nchillis,  154 

of  thigh,   170 


758 


INDEX. 


Muscles    of  thumb,  209 

quadriceps      extensor     eru- 
reus,   179 

quadriceps    extensor    femo- 
ris,  561 

of  uterus,  211 

rectus  abdominis,  194 

shoulder  and  arm,   183 

sphincter  ani,  199 

structure,  249 

tibialis  anticus,   199,   210 

tissue,  204 

trapezius,  158 
Muscular  activity,    77 

contraction,   267,   272,  278 
Myalgia,  456 
Mydriatics,  351,  379 
Myelitis,  441,  472 
Myocariiial  degeneration,  304 
Myocarditis,   490 
Myomata,  293 
Myopia,  266,  273,  526,  540 
Myotics,  336 
Myxedema,  495 

Naevus,  637 

Narcotics,  321,  362 

Narcotine,  23 

Nasal  fossae,  192 

Nascent  state,  41 

Necrosis,  633 

Negroes,    diseases    common    among, 
545 

Neoplasms,  malignant,  305 

Nephrectomy,  604,  607 

Nephritis,    21,    288,    303,    358,    432, 
438,  462,  480,  493,  507,  675 

Nephrolithiasis,   430 

Nephrorrhapy,  604 

Nephrotomy,  604 

Nerves,  afferent,    243,    255 
cells,  230 

effect  of  electricity  on,  219 
efferent,  243,  255 
facial,  185,  234,  569,  615 
fibre,  175,  213,  230 
fifth  cranial,   164,  204,  253, 

614 
fifth  pair,  171 
fourth  cranial,  221 
glossopharyngeal,   177,   198 
median,  167,  555 
motor    oculi,    261 
of  eye, 
of  optic   commissure,   158 


Nerves    of  palm  of  hand,  194 
of  rectum,   170 
of  uterus,  211 
olfactory,  197 
optic,  152,  218 
pharyngeal  plexus,   206 
phrenic,  206 
pneumogastric,      189,      195, 

198,  212,  237,  251 
radial,  199,  607 
saphenous,  206 
sciatic,   159 
sclerosis  of,  298 
sixth,   149,   221 
spinal,  245,  270 
spinal  accessory,  626 
spinal  cord,  243 
superior  laryngeal,  240 
sympathetic,    189,    203,    22« 
third  cranial,  205,  252,  413, 

484 
ulnar,  611 
Nervous  system,   220,   242,   254,   -jO 
Neuralgia,  intercostal,   467 

of  fifth  nerve,   614 
prescription  for,  344 
Neurasthenia,  447 
Neuritis,  456,  458 
Neuromata,   293 
New-born,  hygiene  of,  530,  695,  697, 

698,  734 
"  New  formation,"  296 
Night  sweats,  319 
Nipples,  care  of,  715 
Nitrates,  97 
Nitre,  93 
Nitrites,   97 
Nitro,  definition  of,  61 
Nitrogen,  7,  14,  19,  39,  65,  111 
acids,  102 

oxides  of,  17,  41,  57,  108, 
118 
Nitroglycerin,     93,     103,    330,     333, 

344 
Non-metals,  48 
Normal  salt  solution,  607 
Nose,  214,  265 
Nuisances,  532,  543 
Nursing  child,  hygiene  of,  715 

women,     hygiene     of,     532, 
535,  715 
Nutrition,   236,  275 
Nux  vomica,  314,  317,  321,  361 

Obesity,  242,  275,  311,  522 


INDEX. 


759 


Official  preparations,  31,  509 
Oil  of  turpentine,  16,  395,  509 
of  vitriol,  119 
of  wintergreen,  323 
Ointments,   368,   376 
Oleates,    368 
Olefiant  gas,  32 
Oleomargarin,  515 
Oleoresina  aspidii,  509 
Oleum  erigirontis,  399 

mnrrhuae,   371 

ricini,  383,  392 

sabinae,  399 

theobromatis,   320 

tiglii,  313 
Olfactory  apparatus,  265 
Olive  oil,  24,  399 
Omentum,  159 
Opium,  23,  326,   339,  341,  347,  362, 

376,   378,  388,  400,  510 
Opisthotonos,  410 
Ophthalmia,  552,   717 

gonorrheal,  293 
Ophthalmoscope,  403 
Organic  chemistry,  37 
acids,   96 

compounds,  10,   19,  91,  96 
Organ  of  Corti,   278 
Orthopnea,  410 
Osmium,  76 
Osmosis,  8,  114,  226 
Ossa  innominata,  195 
Ostitis  deformans,  580 
Cvarnlgia,   729 
Ovarian  cyst,  730,  735 
disease,  670 
dropsy,  464 
prolapse,    739 
Ovaries,   190,  729 
Ovaritis,   729 
Ovule,  657 

Over-exertion,  -strain,  -training,  546 
Ovulation,   657 
Ovum,  226,  657,  658 
Oxgall,   382 
Oxidation,  89 
Oxyacids,   101 
Oxygen,  1,  2,  14,  27,  31,  42,  60,  73, 

74,  82,  88,   114,  127,  134 
Ozone,   16,  27,   66,   89,   91 

Paget 's  disease,  557 
Pain,  242 
Pallor,  235 
Palmar  arch,  174 


Palmar  fascia,  190 
Palpation,   668,   672 
Pancreas,   159,   236 
Pancreatic  juice,  21,  242 
Pancreatin,  366 
Pancreatitis,  415 
Pandemic  diseases,  513 
Papillomata,  286 
Papaverine,  23 
Peraeentesis,  600 
Paralysis,  413,  457,  484 

agitans,  440 

bulbar,  298 

diphtheritic,  440 

infantile,  487,   6o^ 

ischemic,  297 
Paraphimosis,   562,   611 
Paraplegia,  410,  495 
Parasiticide,  343,  351,  400 
Paresis,   295 
Paris  green,  89,  93 
Paronychia,  577,  615 
Parotid   duct,   148 
Parotitis,  503,  521 
Patella,  593 

Patellar  reflex,  457,  495 
Pellatierine,  399 
Pelvic    inflammation,    729 
Pelvimetry,   736 
Pelvis,  bones  of,  169,  660 

female,  659,  660,  661,  662 
male,   659 
Pentad,  definition  of,  1,  40 
Pepo,  353 

Pepsin,  21,  71,  90,  366 
Peptones,  47 
Pericardial  effusion,  503 
Pericarditis,  444,  451,  460,  473,  480, 

500,  504 
Pericardium,  159 
Perineum,  680.  690,  738 
Periosteum,   199 
Periostitis,  456 

Peristalsis,   intestinal,  351,  382 
Peritoneum,  163,  165,  200 
Peritonitis,   295,   438,  440,  454,   553 
Perspiration.   237,   260 
Pertussis,  423,  521 
Petroleum   products,    14,   364,  377 
Peyer's  glands,  207 
Phagocvtosis,  281 
Pharmacy,  352 
Pharynx.   168,   177 
Phenncetine,  42,   325,  397 
Phenol,  21,   56,   130 


760 


INDEX. 


Phenol,  products  of,  111 
Phimosis,  582,   611 
Phlebitis,   281,   433,   Ci7,   640 
Phlegmasia  alba  dolens,  700 
Phosphates,  84,  102,  -03,  135 
Phosphorus,  8,  19,  43,  49,  57,  79,  92, 
314,  322,  379,  511 
poisoning,     8,     16,     17, 
341,   399,   522 
Photography,  36,  133 
Phthisis,  458,  470,  496 
Physical  action, 
Physicians,  hygiene  for,  536 
Physiologic  action,  350 
Physics,    79 
Physiology,  269 
Physostigmine,    87,    325,    332,    373, 

396 
Phytolacca,  321 
Pia  mater,  182 
Picrotoxin,   388,  391 
Piknometer,  81 
Pilocarpine,   87,  318,   322,  338,   361, 

375,  384 
Pilocarpitline,  318,  384 
Pilocarpus,  373,  384 
Pix  liquitla,  388 
Placenta,  655,  687,  688,  697 

praevia,  711 
Plaster  of  Paris,  10,  101 
Plastic  inflammation,  299 

operations,  623 
Pleura,  168 

Pleural   exploratory    puncture,    417 
Pleurisy,  429,   467,   499 
Pleuritic  eflfusion,  470,  503 

sounds,  487 
Pleuritis,  409,  414,  421.  467 
Pleurodynia,  409 
Plumbing,  538 
Pneumonia,  290,  419,  454,  465,  475, 

476,  498,  499,  505,  552 
Pneumonic  fever,  482 
Pneumonitis,  277,  411,  421,  428,  481 
Podophyllin,  377,  394 
Poisons,  62,  67,  76,  123,  273 
Polarization,   3 
Polymeric,  62 
Pomegranate,  399 
Pons  varolii,  164 
Popliteal  space,  202 
Porosity,  8,  93 
Porro  's  operation,  725 
Portal  circulation,  238 


Post-mortems,  229,  292,  311 
Postpartum  hemorrhage,  701 
Potassium,  40,  105,  133 

compounds,    10,    12,    14, 
22,  28,  34,  55,  82,  126, 
130,     138,     b29,     330, 
383,     384,     389,     393, 
398 
cyanide,  92 
group,  39,  107 
iodide,  4,  28,  366 
Poupart's -ligament,  160 
Precipitate  definition  of,  80 
Pregnancy,  279,  662,  663,  667,  668, 
669,     670,     671,     672, 
675 
albuminuria  in,  674 
ectopic,  679,  680 
diagnosis   of,   261,    666, 

672,  735 
hydatid,  659 
hygiene  of,  540,  673 
multiple,  718  735 
pathology   of,   673,   675, 

734,    735,    738,    743 
presentations     in,     672, 

673 
tubal,  680 
Premature  birth,  676,  679,  694 
Prescriptions  containing    an    alkali, 
394 
an   astringent,   394 
an  expectorant,  341 
an  opiate,  303 
a  sedative,  341 
a    rubefacient,    379 
camphor   water,  326 
chlorate    of    potash, 

329 
chloride  of  iron,  329 
corrosive    suDlimate, 

343,  345 
hydrochloric       acid, 

326 
iodide  of  potassium, 

345 
iron,  396 

iron  sulphate,  344 
muriate     of     ammo- 
nia, 393 
nitrate      of      silver, 

360 
oil    of    sandalwood, 

362 
opium,  344 


INDEX. 


761 


Prescriptions  containing     syrup     of 
wild    cherry,    356 
for  a  bronchial  cough, 
341 
a  collyrium,  359 
a  mouth  wash,  359 
a  parasicitide,  343 
a  stomachic  in  al- 
coholism,  336 
a  suppository,  359 
bronchitis,   376 
chronic        cystitis, 

362 
cough         mixture, 

326,  393 
diarrhea,  361,  394 
insomnia,   334 
neuralgia,  344 
rheumatism,    acute 

articular,  331 
scabies,  346 
syphilis,   345 
incorrect,  361,   365 
metric,  370,  399,  400 
Presentations     in     child-birth,     682, 
6S3,  6S4,  685.  703,  704,  703,  706, 
707,  70S 
Preservative,  9 
Preventaljle  diseases,  517 
Privies,  hygiene  of,  534,  539 
Productive   inflammation,  286 
Prophylaxis,  518 
Prostate,   166 
Prostatectomy,  589 
Prostatitis,  573 
Proteids,  22,  253 
Protoplasm,  253,  258 
Psoriasis,  419 
Pseudocycsis,    671 
Ptomaines,   28,  521 
Ptosis,  413,  642 
Ptyalin,  71 
Puberty,  in  female,  659 

in   male. 
Puerperal  state,  096 
breasts,  736 
convulsions,  714 
sepsis,  699,  700 
mania,  714 
Pulmonary  abscess,  459 
diseases,  520 
edema,  445 
solidification,   474 
sounds,  455 
Pulsatilla,  350 


Pulse,  222,  235,  416,  433 

Pulvis  glycyrrhizae   comp.,  319,   357 

jalapae  comp.,  324 
Purgatives,  9,  364,  381,  383 
Purin  bases,  280 
Purpura  hemorrhagica,  oOO 

simplex,  484 
Pus,  293,  308,  541 
Pustule,  malignant,  622 
Putrefaction,  77,  100,  116,  134 
Pyelitis,   439 
Pyemia,  609,  612 
Pylorus,    174 
Pyogenic  bacteria,  297 
Pyroxylin,  15,  91 
Pyuria,  435 

Quarantine,  526 

diseases  subject  to.  526 
Quassia,   350 

Quickening  in  pregnancy,  608 
Quinine,  16,  54.  314.  364,  377.  378. 

389 
Quinsy,   505 

Rachitis,  430,  460 
Ra<lical,  14,  53,  92.   114 
Radium,  70 
Rales,  481 
Ramus  of  jaw,  205 
Rattlesnake   bite,  638 
Reaction,  3,  98 
Reagent,  3,  40 
Rectal  feeding, 
Rectocele,  730 
Rectum,  180,  208,  732 

stricture  of,  604 
Reflex  action,  221,  249.  271 
Reflexes,  the,  245 
Reinsch  's  test,  122 
Remittent  fever,  455 
Renal  circulation,  233 
colic,  486,  499 
degeneration,    305 
Reserve   air,  268 
Residual  air,  268 
Resorcin,    374 
Respiration,  214,  220,  224,  231.  243. 

258,  267,  270,  277,  416,  422,  478, 

534,  .541,  719 
Respiratory  sounds,  203,  478,  483 
Rest  cure,  265 
Retina,  213.  249 
Retropharyngeal   abscess,  497 


762 


INDEX. 


Rheumatism,  386,  407,  456,  458,  465, 

474,  475,  480,  498,  536 
Rheus,  511 
Rhubarb,  391 
Rigor  mortis,  228,  260 
Rochelle  salt,  89 
Roentgen  ray,  104,  488 
Roseola,    454 
Rotheln,  506,  521 
Rubella,   450,  484 
Rubeola,  469,  484,  506 

Saccharin,  392 

Sacro-iliac  disease,   563,  612 

Safety  lamps,  90 

Sal  ammoniac,  10,  12,  115 

Saline  purgative,  381 

Saliva,  22,  72,   120 

Salivary  glands,   155,   373 

Salol,    370,    402 

Salpingitis,    728 

Salt,  10,  40,  62,  75,   279 

normal   solution,   607 
Saltpetre,  400 
Salts,  definition  of,  2 
acid,  2 
double,  2 
neutral,   2,    137 
Santalum,  374 
Saponification,   126,  251 
Sarcoma,  284 
Sarsaparilla,  385 
Saturation,  120 
Scabies,  346 
Scalp  wounds,  558 
Scammonium,  354 
Scarlatina,  290,  442,  454,  471,   476, 

484 
Scarlet,    fever,   441,   449,   473,    477, 

491,  505,  506,  509 
Scarpa's  triangle,  165,  171,  211 
School,  hours  of,  526 
houses, 
hygiene,  538 
life,    diseases    of,    526,    527, 

540 
rooms,  535 
Sciatica,  426 
Sclerosis,  298 

multiple,  449 
Scoparius,  356 
Scrotum,  265 

affections  of,   597 
Scruple,  30 
Scurvy,   437 


Sebaceous  glands,  232 
Secretion,  231,  242,  253,  308 
Sedative,  341,  362,  385 
Segmentation  of  ovum,  226 
Seidlitz  powder,  90 
Selenium,  140 
Semen,   656 
Seminal  fluid,  263 
Senile  changes,  301 
Senna,  357,  379,  398 
Sepsis,  699,  732 
Septicemia,   612 
Serpentaria,  357 
Serum  therapy,  363 
Sesqui,  40 

Sewage  disposal,  541,  552 
Sewer  gas,  515,   544 
Ships,  hygiene  of,  522 
Shock,  624,  634 
Shoulder  joint,  157,  590 
Sialogogue,   333,   392 
Sick  room,  538 
Sigmoid  flexure,  184 
Silicon,    140 

Silver  and  salts  of,  10,  18,  30,  38, 
73,  76,  82,  90,  97,  107,  128,  132, 
358,  371,  389,  394,  406,  509 

Sinapis,  320 

Sinus,  193,  609 

Sinuses  of   face,   193 

Skeleton,  79 

Skin,  187,  239,  245,  257,  272,  287, 
288,  336,  373,  472,  484,  536 

Skull,  fractures    of,    557,    561,    592, 
622 
trephining,  561,  648 

Sleep,  263,  276,  376,  530 

Small-pox,  419,  442,  450,  459,  461, 
534 

Smell,  sense  of,  219 

Snakeroot,   357 

Soap,  09,  110,  139,  398 

Sodium,  80,  82 

compounds  of,  9,  10,  12,  13, 
21,  42,  53,  63,  111,  129, 
279,   324,  349,   366,   511 

Soils,   517 

Solar  plexus,  153 

Solid,  7,  37 

Solution,  80 

Solvent,    348 

Soot,  102 

Sound,  sensation  of,  257 

Sparteine,   323 

Spasms,  497 


INDEX. 


763 


Special  senses,   243 

Specific  gravity,   3,    37,   55,    /5,    79, 

81,    89 
heat,  5,  117 
Spectroscope,  4 
Speech  center,  242 
Spermatic    cord,    167 
Spermatozoa,    656 
Sphincter  ani,  199 
Sphygrmograph,   229,   250 
Spigelia,  367 
Spina  bifida,  293 
Spinal  column,   176,   187,  210 

cord.  196,  213,  214,  229,  243, 

268,  293,  296 
Spirits,  344 
Spleen,  169,  210,  420 

in  fevers,  420,  502 
in  leucocythemia,  268 
Sprain,    625 
Sputum,  289,   419,   422 

disinfection,    527 
Squills,   398 
Stammering,  273 
Staphisagria,  343 
Starch,   l5,   77,   81,   103,   241 
Static  electricity,  10 
Stenosis,  285,  553.  623 
Stenson's  duct,   174,  233 
Sterility,  676,   742 
Sterilization,    129 
Still-birth,   229,   671,  720 
Stimulants,  386 
Stomach,  174,  235,  243 

absorption   from,   236 

cancer  of,   417,   446,   641 

distension     of,     234,     437, 
488 

foreign  body  in,  573 

lesions  of,  488 

movements  of,  254,  278 

pnmp,  16 

ulcer  of,  431 
Stomachic,  336 
Stomatitis,  495 
Strabismus,    608 
Stramonium,  87 
Strontium,  76 
Strophanthus,  331,  347 
Strychnine,    .54.    97.    317,    321.    328, 

336,  373,  406,  508,  511 
St.  Vitus'  dance,  424 
Styptic,  352,  395 
Sub,   definition   of,   61 
Subinvolution.  693.  696.  698 


Sublimation,    10,   50 

Sublingual  duct,  148 

Submaxillary  duct,  148 

Sucrose,  33,  59 

Sudoriferous  glands,  232 

Sugar,  cane,  17 
^  classes  of,  17,  33,  52 

of  milk,  392 

Sulphate,   107 

Sulphite,    107 

Sulphonal,  400,  406 

Sulphur,  2,  9,  14,  19,  31,  51,  55,  76, 
82,  94,  121.  141,  3^3,  3oO 
ointment,  349,   4u0 
oxides  of,  7,  31,  74,  109 

Sulphuretted  hydrogen, 

Sunstroke,   426,   462,   501 

Superfetation,  718 

Suprarenal  capsules,  201 

Surgical  fever,   560 

instruments,  572 

Sutures,  638 

of  skull,  155 

Symbiosis,    300 

Symbol,  90,  116 

Sympathetic  nerve,  189,  203,  228 

Symphyseotomy,  724 

Symptoms  of — 

abdomnial   aorta,   aneurysm    of, 

417 
abortion,  677 

abscess,  acute  ischio-reetal,  650 
abscess,  mammary,  716 
abscess,  peritonsilar,  505 
abscess,   retropharyngenl,   497 
abscess,  vulvo-vaginal.  565 
acetanilid  poisoning,  506 
acute  articular  rheumatism  with 

endocarditis,  408 
albuminuria  in  pregnancy,  674 
aneurysm    of    abdominal    aorta, 

417 
appendicitis,  473,  491 
appendicitis,  recurrent,  420 
apoplexy,  497 
asphyxia  in  new-born,  697 
atrophy,  optic,  418 
atrnnhy,    progressive    muscular, 

482 
brain,  .syphilitic  tumor  of,  412 
brain,  tumor  of,  636 
bronchitis,  diffuse,  423 
carbolic  acid   poisoning,  509 
chancroid,  640 
cirrhosis  of  the  liver,  425 


764 


INDEX. 


Symptoms   of — 

congenital   inguinal  hernia,   590 

croup,  spasmodic,  423 

delirium  tremens,  471 

dementia,  414 

diabetic  coma,  408 

diphtheria,  418,  479 

eclampsia  gravidarum,  713 

ectopic  pregnancy,  679 

eczema  squamosum,  419 

epilepsy,  487 

erysipelas,  412,  623 

erysipelas,  idiopathic,  465 

erythema,  412 

foreign  body  in  stomach,  573 

fracture  of  base  of  skull,  592 

fracture  of  base  of  skull  in 
middle  fossa,  022 

fracture  of  nasal  bones,  569 

fractures,  643 

gall  stones,  impacted,  436 

gangrene  of  lung,  409 

gastralgia,   448 

gastric  ulcer,  505 

gastritis,  420 

gastritis,   acute,  416 

glaucoma,  acute,  414 

glaucoma,  chronic,  418 

goitre,  exophthalmic,  412,  447 

hammer-toe,   631 

hemorrhage  from  middle  men- 
ingeal artery,  568 

hemorrhage,  gastric,  408 

hemorrhage,  pulmonary,  408 

hepatization  of  the  lung,  414 

hernia,  congenital  inguinal,  590 

hernia,  strangulated,  633 

hydrocephalus,   468 

intestinal  obstruction,  650 

intestinal  perforations  in  ty- 
phoid, 506 

inversion  of  uterus,  712 

iritis,  407,  414 

ischiorectal  abscess,  acute,  650 

keratitis,  407 

kidney,  prolapsed,  420 

lead  poisoning,  431 

lung,  gangrene  of,  469 

lung,  hepatization  of,  414 

lung,  solidification  of,  474 

malaria,  413 

mania,  puerperal,  714 

mastitis,  puerperal,   715 

mastoiditis,  415 

median  nerve,  section  of,  555 


Symptoms   of— 

melancholia,  414 

meningitis,  tubercular,  409 

middle  meningeal  artery,  hem- 
orrhage from,  568 

migraine,  494 

morbus  coxae,  558 

myleitis,  acute,  472 

myocarditis,   490 

naevus,  637 

nasal  bones,  fracture  of,  569 

nephritis,  acute  exudative,  493 

nephrolithiasis,  420 

ophthalmia  neonatorum,  717 

pancreatitis,  415 

paralysis  of  phrenic  nerve,  457 

perforations,  intestinal,  in  ty- 
phoid, 506 

pericarditis,  451 

pericarditis  with  fffnaion,  acute 
504 

phlebitis,  617 

phlebitis,  puerperal,  700 

phlegmasia  alba  dolens,  701 

phrenic  nerve,  paralysis  of.  457 

placenta  praevia,  711 

pleuritis,  407 

pleurodynia,  409 

pneumonia,    476,    505 

pregnancy,  ectopic,  679 

prolapsed  kidney,  420 

psoriasis,  419 

puerperal  mania,  714 

puerperal  mastitis,  715 

puerperal  phlebitis,   700 

purpura  hemorrhagica,  500 

pyemia,   609 

quadriceps  extensor  femoris, 
rupture  of,  561 

rheumatism,  acute  inflammatory 
articular,  465,  474 

rubeola,  469 

rupture  of  quadriceps  extensor 
femoris,   561 

scarlet  fever,  473,  505 

sclerosis,  multiple,  449 

section  of  median  nerve,  555 

shock,  634 

skull,  fracture  at  base  of,  592 

skull,  fracture  of  base  of,  in 
middle   fossa,   622 

solidification  of  lung,  474 

sprain,  625 

stomach,  dilatation  of,  437 

stomach,   foreign  body  in.   573 


INDEX. 


7H.> 


Symptoms  of — 

strangulated  hernia,  633 

syphilis,  502 

syphilitic    tumor   of    the   brain, 
■  412 

tetanus,  466 

tonsilitis,  418 

tuberculosis,   incipient,   417 

tuberculosis,  miliary,  421 

tumor,  of  brain,  636 

tumor,   syphilitic   of   the    brain, 
412 

typhoid  fever,  441 

typhoid,   intestinal   perforations 
'  in,   506 

ulcer,   gactrie,  505 

uterus,   inversion   of,  712 

vaginitis,   acute,   61S 

varicocel,  574 

vulvo-vaginal   abscess,   565 

yellow  fever,  456 
Synarthrosis,    157 
Syncope,  263,  461 
Synovial  biirsae,  608 

fluid,   135 
Synovitis,  602 
Synthesis,  82,  94,  98 
Syphilis.    286,    345.    464,    502.    506, 

550.  643,  719 
Syphilitic  gummata,  298,  376.  412 
Syrup  of  wild  cherry,  326 

Tabes  dorsalis,  467 

Tactile  sense,  213 

Talipes  calcaneus,  562,  616 

cqiiino-varns,   571,    (517.    621 

pquiniis.   572,   616 
Tallow,  24 
Tampon,  702 
Tannic  acid,  70,  87 
Tannin,    131 
Tape   worms,  445.   489 
Tar,  345 
Taraxa<?um.  356 
Tartar,  dental,    104 

emetic,  55,  351,  3.53,  388 
Tartaric  acid,  116.   123,   138 
Taste,  276 
Tea,  253,  544 

drinking,  544 
Tears,  22,  72,  235,  275 
Teeth,  184,  231,  239,  265.  271.  536 
Tellurium,  S2 
Tomporatun",   2().   540 


Temperature     of     body,     229,     231, 
244,  26»,  269.  272,  409.  410.  411. 
416,  473,  483,  504 
Temporo-maxillary  articulation,   18ft 
Tendo  Achillis,  154 
Tendons,  152 
Tfnia,  489 

Testes,   166,   195,   265 
Tests  for  acetone,  142,  145 

albumin,    25,    29,    45,    55, 
78,  85,  108 

albumose,  142 

alum,  133 

arsenic.  11,  31.  54.  71,  83, 
122 

barium,   76 

bile,  85,  145 

bilirubin,  142 

blood,  86,  141,  145 

calculi,  uriaary,  143 

calomel,  52 

chlorides,  33,  78,  87 

chlorine,   87 

diacetic  acid,   142 

ferric  salts,   11,  12 

ferrous  salts,  9,  12 

formaldehyde,   72 

glucose,  47 

hemoglobin.   24 

hydrargyrum,   lu.  30.  52 

hydrocarbons,  87 

hydrochloric  acid,  87,   142 

bydrocyanii-    acid,    134 

impurities   in   water.  514 

indican,  7H,  134 

lead,  58 

mercury,   10,  30,  52 

morphine,   62 

mucin,    86 

organic    matter.    112 

ozone,   66 

sewage,  87 

silver,  30,  132 

starch,   15 

strontium,   76 

strychnine,  377 

sugar,  SI,  S6,    102 

sulphates,  78 

sulphuric  acid,  122 

urates,   115,   117 

urea,  58,  78 

uric  acid,  24,  86,  115 

urinary  calculi,  143 

water,  87 

watiT.    impurities    in.    541 


766 


INDEX. 


Tetanus,  228,   243,  425,  466 

Tetrad,  definition  of,  1 

Tlierapeutic  action,  352,  350 

Therapeutics,  definition  of,  330,  350 

Thermometers,  65,  69,  103 

Thigh  amputation,  587 

Thirst,  220 

Thoracic  duct,  168 

Thorax,   207,    463 

Thrombosis,  285,  500 

Thrombus,  640 

Thymol,  345 

Thymus,    201 

Thyroid,   150,  262 

Thyroidectomy,  564 

Tic  douloureux,  491 

Tidal  air,  268 

Tinctures,  318,  344,  376,  380 

Tinnitus  aurium,   645 

Tissue,  254,  255,  291,  292,  301,  305, 

572,  612 
Tobacco,   evils   of,   529,   540 
Tongue,  182,  642 

excision  of,  553 
in  diagnosis,  416,  456 
Tonsilitis,   410,  418,  459,  492 
Tonsils,  207 
Topical  remedies,  404 
Torticollis,  610 
Toxins,  547 
Trachea,  187 

foreign  body  in,  570 
Tracheotomy,  206,  560 
Trephining,  561,  648 
Triad,  2,  5 
Trichinosis,  322 
Trypsin,   2i 
Tubal  pregnancy,  679 
Tubercle  bacilli,   289,   302 
development,  306 
Tubercles,  284,  309 
Tubercula  quadrigemina,  156 
Tubercular  formation,  305 
joints,  296,  310 
meningitis,   407,   469 
peritonitis,  438 
ulcer,  297 
Tuberculosis,  287,  302,  309,  410,  413, 

417,  421,  452,  482,  513,  519,  543, 

549,  550 
Tully's  powder, -349 
Tumors,  284,  298,  305,  412,  561,  594, 

595,  597,  616,  619,  636,  637,  735 
Turpentine,   121,  347,  480 
Tympanum,  604 


Typhoid,  307,  410,  411,  419,  433, 
444,  445,  446,  455,  459,  463,  466, 
474,  489,  493,  504,  506,  521,  522, 
542,  551,  648 

Typhoidal  ulcer,  297 

Typhus  fever,  439,  452,  478 

Tyrotoxicon,  520 

Ulceration,  300,  582 
Ulcer,  gastric,  453,  457,  505 
Umbilical  cord,   658,   659,  694,  743 
hemorrhage,   720 
soufifle,  668,  671 
Undervrear,  material  of,  545 
Union,  delayed,  641 
Urates  in  urine,  84,  115 
Urea,  20,  24,  101,  122,  145,  227,  307 
Uremia,  21,  327,  410,  432,  461 
Ureter,   147,   206 
Urethra,   153,  208 
Urethritis,  557 
Urinary  calculi,  24,   102,   143 

deposits,   84 
Urination,  269,  675 
Urine,  appearance  of,  134 

amount  of,  35 

casts  in,  284,  501 

composition   of,    20,   29,    54, 

108,  131,    137,    144,    225, 
237,  262,  271,  500 

cystitic,  136,  480 
effect  of  benzoin  on,  384 
examination    of,    29,    37,    38, 
44,  73,  77,  81,  85,  86,  102, 

109,  117,    142,    143,    144, 
145,   410 

in  diabetes  mellitus,  473 
in  health,  259 
in  nephritis,  136 
in   rheumatism,   480 
pigments   in,   87 
pus  in,  571 

reaction  of,  46,  103,  271 
specific    gravity    of,    21,    22, 
44,  108,  109,   131,  271 
Urinometer,   75,   81,   105 
Urobilin,  87 
Urochrome,  87 
Urticaria,  321 
Uterine  bruit,   668,   671 
colic,  499 
fibroid,  735 
fibromata,  739 
hydatids,  659 
inertia,  691,  7  09,  744 


INDEX. 


767 


727, 


I,  723 
738 


737 


Uterine  mucous  membrane,  234 
Uterus,  200,  211,  655,  662,  668  ! 

after   pregnancy,   234,   699    i 
anteversion  of,  727  , 

cancer  of,  731 

contraction  of,  709 
curettage  of,  714 
dilatation  of,  712,  728 
displacement    of,    675. 

738 
fixation   of,    728 
hemorrhage  of,  710,  711 
inversion  of,  712,  737, 
ligaments  of,   162 
malformation   of.    726 
prolapsus  of,  727,  737 
retroversion  of,  727 
rupture  of,  710,   742 
ventrofixation    of.    728. 
Uva  ursae,  326,  371 


Vaccination  518,  520,  543,  547 

Vaccinia,  467,  521 

Vagina,  157,  663,   699,   732 
atresia  of,  741 

Vaginal  douche,  692 

Vaginismus,   727,  740 

Vaginitis,   618,   740 

Valence,  92 

Valerian,  371 

Varicella.  450,  461,  484.  521 

Varicocele,  574 

Varicose  veins,  646 

Variola,  411,  419.  442.  450.  459.  461, 
467,  516 

Varioloid,  472 

Varix,  640 

Vascular  system,  334 

of  new-born.   209 

Vaseline,  64 

A^eins,  250,   274 

cerebral,   199 
external  jugular,  205 
internal  iugular.  170 
pulmonary,  187 
saphenous,  206 
subclavian,   151 

Vena  cava.  178,  185 

Venesection,   357 

Venous  blood  current,  255 

Ventilation,  530.  .531,  .538 

Ventrofixation,   728.    737 

Ventriloquism,  228 

Ventrosuspension,  737 

Veratrum.  325,  .337,  395,  511 


Verdigris,  102 

Version,  723,  724 

Vertebrae,  173,  176 

Vertigo,  435 

Vesicants,  394 

Vesiculae  seminales,  198,  263 

Vienna  paste,  350 

Vinegar,  15,  102.   122 

Vision,  224 

ViteUus,  658 

Vocal  cords,  148,  223,  233 

fremitus,  500 
Vocational  diseases,  524 
Voice,  255,  277 
Volvulus,  600 
Vomiting,   238,   334,   434 
Vomitus,  421 
Vulva,  736 
Vulvo-vaginal  abscess.  565 

Wall  paper,  516 

Water,  30,  35,  37,  122,  372,  535 

analysis  of,  98 

contamination     of    87.     523. 
524,  539,  545 

decomposition  of,  29 

detection    of    impurities    in, 
87,  140,   142,  541 

diseases    conveyed    by,    542, 
548 

freezing  point  of.  107 

ground,  531 

hard  and  soft,  547 

mineral,  27.  65.  90,  122,  135, 
372 

natural,  66 

of  crystallization,  3,  41 

oflScial,  383 

purification  of,  106.  118.  .539 

synthesis    of,    98 

uses   of,   339 
Waxy  degeneration,  298 
Webbed  fingers,  636 
Wells,  523 
Wet  pack,  372.  527 
Whiskey,  79 
Wild  cherry,  383 
Whooping  cough,  439,  444 
Willow,  preparations  from.  363 
Willis,  circle  of,  180,  212 
Wine,  39,  79 

adulteration  of.  518 
Witch   hazel,    353 
Wolffian  bodies,  236 
Wormian  bones,  200 


768 


INDEX. 


Wounds,  591,  595,  608 

chances  of  survival   from, 

260 
classification  of,  598 
gunshot,  591 
infection  of,  608 
Wrist,  amputation  of,  581 

joint,  169 
Wry-neck,  579 


X-rays,   104,  488 

yeast,  117 

Yellow    fever,    436,    440,    456,    514, 
544 

Zinc,  38 

preparations  of,  44,  396 

salts  of,   13,  44 
Zingiber,  352 


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